Headache Medicine 2021, 12(2) p-ISSN 2178-7468, e-ISSN 2763-6178

148

ASAA

DOI: 10.48208/HeadacheMed.2021.27

Headache Medicine

Case Report

Vertebral artery hypoplasia and chronic migraine: is there an

association or just an incidental nding?

Patrick Emanuell Mesquita Sousa-Santos , Gabriela Figueiredo Pucci , Juliana Akita

São Paulo State University, UNESP, Botucatu, São Paulo, Brazil.

Abstract

We describe a 29-year-old woman with chronic migraine and psychiatric comorbidities that

presented with new transient left-sided hemiparesis and hemi-hypoesthesia and were found

to have right vertebral artery hypoplasia (VAH). We briey review the association of VAH

and migraine and the inuence of psychiatric disorders and VAH as possible risk factors for

chronication of episodic migraine. Despite uncertain mechanisms, VAH may be one of the

contributing factors for the chronicity of migraine.

Patrick Emanuell Mesquita

Sousa-Santos

Av. Professor Montenegro s/n,

Rubião Júnior, 18618-687,

Botucatu-SP-Brazil.

Email: patrickemanuell@gmail.

com

Edited by:

Marcelo Moraes Valença

Keywords:

Vertebral artery

Chronic migraine

Psychiatric comorbidity

Nervous system diseases

Anatomy.

Received: August 25, 2021

Accepted: October 5, 2021

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Sousa-Santos PEM, Pucci GF, Akita J

Vertebral artery hypoplasia and chronic migraine: is there an association or just an incidental finding?

Introduction

ertebral artery hypoplasia (VAH) is an uncommon vari-

ation of the posterior circulation. It was rst described

in the 19th century, with a prevalence varying from 2 to

6% found on autopsy and radiological exams.

Despite this

prevalence, little is known about its clinical relevance, and

recently, VAH has been considered a risk factor for migraine

with aura, vestibular migraine, and posterior circulation

stroke.

The frequency of VAH can be as high as four times

higher in patients with migraines with aura when compared

to controls.

Moreover, few studies address the therapeutic

responses in these patients. We describe a case of vertebral

artery hypoplasia in a patient with chronic migraine associat-

ed with psychiatric disorders and briey review the literature.

Case Report

A 29-year-old woman with a previous history of migraine

without aura was admitted to the emergency department

(ED) of a tertiary neurological center with new sudden

onset of left-sided hemiparesis and hemihypoesthesia,

with a duration of one minute. After these symptoms, she

developed a headache with migraine characteristics,

identical to her previous episodes. She denied any other

previous episodes or familial history of similar symptoms.

Her previous headaches were characterized by left

hemicranial, pulsatile, moderate to severe intensity,

associated with nausea, vomiting, photophobia,

phonophobia, and osmophobia, and have presented daily

since adolescence. The duration was between 12-24 hours

and used to improve with analgesic (dipyrone 500 mg or

dipyrone 300 mg + caffeine 50 mg + orphenadrine 35

mg). She has been taking these medications more than 15

days per month in the last two years.

She also had a history of anxiety, depression, asthma, and

obesity (BMI 39 kg/m

). She denied a previous history of

transient ischemic attack or stroke. In addition to simple

analgesics, she used uoxetine (40 mg per day) and

combined oral contraceptive.

On ED evaluation, the neurological examination was

normal. Complete metabolic panel and blood glucose

were unremarkable. The headache resolved one hour after

treatment with intravenous naproxen.

A brain computed tomography with perfusion and a cerebral

and a cervical computed tomography angiography were

requested to investigate the new neurological symptoms.

Imaging exams showed a hypoplastic right vertebral

artery, with no other abnormalities (Figures 1 and 2).

The remaining laboratory tests, including investigation

of vasculitis and other autoimmune diseases, were

unremarkable.

Figure 1. Digital reconstruction of cerebral and cervical CT

angiography. The arrow shows the hypoplasic right vertebral

artery, with little contrast lling.

Figure 2. Axial CTA showing the difference in caliber of the right

(A) and left (B) vertebral arteries.

She was diagnosed with chronic migraine and prescribed

topiramate with a progressive dose increasing up to 100

mg per day as a preventive treatment for migraine.

Discussion

Computed tomography angiography has been proposed

as a safe method as an alternative to cerebral digital

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Sousa-Santos PEM, Pucci GF, Akita J

Vertebral artery hypoplasia and chronic migraine: is there an association or just an incidental finding?

subtraction angiography (DSA), considered the gold

standard for studying cerebral circulation. However, since

DSA is an invasive procedure, and the risk of developing

neurological complications can be as high as 1%

, we

decided not to perform it in this patient, as no additional

benet would be obtained for her diagnosis or treatment.

An association between migraine and VAH emerged

in a study done by Laurevic and colleagues, in 1998

which showed a prevalence of 29% of VAH in patients

with migraine with aura comparing to 7% in patients with

migraine without aura. In this article, a pathophysiological

model was proposed, in which VAH was related to

decreased posterior circulatory ow during migraine

attacks, thus contributing to the manifestation of the aura.

Later, Chung et al.

found a similar prevalence of VAH in

migraine with aura (28.26%), 14 times higher compared

to controls. However, no decrease in vertebral artery ow

was found in patients with VAH during migraine attacks.

Wherefore, the role of the VAH in migraine may not

involve hypoperfusion during the attack phase but yet may

contribute to migraine through complex neurovessels pain-

producing trigeminovascular pathways mechanisms.

1,3

Thus, it is plausible that VAH could be a contributing factor

to the process of chronication of episodic migraine (Figure

3).

Figure 3. The role of VAH and Migraine. VAH, vertebral arteria

hypoplasia; TVP, trigeminovascular pathways; BMI, body mass

index.

Chronic migraine (CM) is dened as frequent headache

attacks with at least 15 headache days per month for

more than 3 months, and in at least 8 days per month with

migraine characteristics.

There are several predisposing

factors to the chronication of a migraine, such as overuse

of analgesics, inadequate prophylactic treatment for

migraine and stressful events, high BMI, in addition to

sensitization of the trigeminal system and various molecular

mechanisms, such as calcitonin gene-related peptide

(CGRP) and serotonin (5-HT).

Our patient presented some

predisposing factors for CM associated with obesity and

psychiatric comorbidities.

Therefore, management of CM includes a rigorous control

of risk factors, acute pain relief, and effective prophylactic

treatment of migraine.

Another fundamental step in

CM is the treatment of psychiatric disorders and other

comorbidities. The overlapping symptoms of migraine,

anxiety, and mood disorders make the treatment very

challenging. Once the concept of migraine/tension-

type headache and depression/anxiety are continuum

pathologies, it is reasonable to think of a possible spectrum

or continuum between migraine and anxiety/mood

disorders.

Few studies have analyzed the most effective

medications for patients with these three conditions, and

a rational approach based on the main symptoms may be

an option.

Topiramate, at a daily dose of 100 mg, is generally an

effective and tolerable prophylactic drug to CM.

Other

preventive medications, such as amitriptyline, valproate, and

pregabalin, have also been shown to be effective in some

studies.

Considering pain relief, tricyclic antidepressants

(amitriptyline, nortriptyline) seem to be more effective

than SNRIs selective serotonin/norepinephrine reuptake

inhibitor) and SSRIs (selective serotonin reuptake inhibitor).

However, the treatment of anxiety and depression has

better responses to SNRIs and SSRIs, and doses of tricyclic

antidepressants are often higher than those used for the

preventive treatment of migraine, making it difcult to be

tolerated.

In our patient, we chose to start topiramate

for migraine prophylaxis and maintain uoxetine, as she

showed an adequate response to anxiety and depression.

Conclusion

Despite the role of VAH in migraine being unclear, VAH

may contribute to the chronication of migraine through

complex pain-producing trigeminovascular pathways

mechanisms. However, it is important to be aware of factors

such as overuse of analgesics and psychiatry comorbidities

for the adequate treatment of chronic migraine.

Declaration of conflicting interests: The authors declared

no potential conicts of interest with respect to the research,

authorship, and/or publication of this article.

Funding: The authors received no nancial support for the

research, authorship, and/or publication of this article.

Author's Contribution: PEMSS, conceptualization, data

curation, writing – original draft; GFP, data curation,

151

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Sousa-Santos PEM, Pucci GF, Akita J

Vertebral artery hypoplasia and chronic migraine: is there an association or just an incidental finding?

writing – review & editing; JA, supervision, data curation,

writing – review & editing.

Patrick Emanuell Mesquita Sousa-Santos

https://orcid.org/0000-0002-7729-7303

Gabriela Figueiredo Pucci

https://orcid.org/0000-0002-6597-6106

Juliana Akita

https://orcid.org/0000-0002-2645-5543

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