Headache Medicine 2021, 12(2) p-ISSN 2178-7468, e-ISSN 2763-6178
DOI: 10.48208/HeadacheMed.2021.27
Headache Medicine
© Copyright 2021
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.
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
Av. Professor Montenegro s/n,
Rubião Júnior, 18618-687,
Email: patrickemanuell@gmail.
Edited by:
Marcelo Moraes Valença
Vertebral artery
Chronic migraine
Psychiatric comorbidity
Nervous system diseases
Received: August 25, 2021
Accepted: October 5, 2021
Sousa-Santos PEM, Pucci GF, Akita J
Vertebral artery hypoplasia and chronic migraine: is there an association or just an incidental finding?
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
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
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.
Computed tomography angiography has been proposed
as a safe method as an alternative to cerebral digital
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.
Thus, it is plausible that VAH could be a contributing factor
to the process of chronication of episodic migraine (Figure
Figure 3. The role of VAH and Migraine. VAH, vertebral arteria
hypoplasia; TVP, trigeminovascular pathways; BMI, body mass
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
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.
preventive medications, such as amitriptyline, valproate, and
pregabalin, have also been shown to be effective in some
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
In our patient, we chose to start topiramate
for migraine prophylaxis and maintain uoxetine, as she
showed an adequate response to anxiety and depression.
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,
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
Gabriela Figueiredo Pucci
Juliana Akita
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