CE - LETTER TO THE EDITOR

Framing comorbidities and co-occurrences in a migrainewith aura patient: author’s reply

Luca Naldi • Margherita De Stefano •

Andrea Berni • Marco Torri • Loredana Poggesi

Received: 12 May 2014 / Accepted: 16 May 2014

� SIMI 2014

Dear Editor,

We would like to thank Dr. Negro and colleagues [1] for

their interest in our case record ‘‘A challenging multifac-

torial migraine with aura’’ [2] and for the acute observa-

tions that enable us to gain further insights into the clinical

case we reported. Dr. Negro points out that migraine with

aura (MwA) cannot be defined as ‘‘multifactorial’’ as in the

title of our case record, since MwA is a primary headache

according to the diagnostic criteria listed in the 2013 3rd

edition of the Classification of Headache Disorders (ICHD-

3 b) [3]. We agree that no pathophysiological connection

exists between spontaneous cervical artery dissection

(SCAD) and aura in MwA, and also in accordance with the

accurate description by Dr. Negro about electrophysio-

logical events such as cortical spreading depression, which

is the likely underlying mechanism of aura. However, our

intention was not to focus on the pathophysiology of MwA,

but to unravel a particular case of SCAD, noteworthy for

the clinical presentation as well as for the coexisting causes

of transient neurological manifestations combined with

headache.

In our case, the localization of headache secondary to

artery dissection was occipital and bilateral. However, two

thirds of patients with spontaneous carotid artery dissection

experience unilateral headache ipsilateral to the dissected

artery, mainly in the frontal or fronto-temporal area [4].

Indeed, headache has no constant specific pattern in carotid

artery dissection, and—especially for atypical presentation,

it can be very misleading, mimicking other headaches such

as migraine. Finally, our patient’s SCAD did not associate

with highly suggestive local neurological signs (e.g., sud-

den-onset partial Horner’s syndrome) that can be present in

up to 50 % of cases when the carotid artery is affected [5].

The patient also presented with a patent foramen ovale

(PFO) as a potential concomitant cause of focal neurolog-

ical deficit. We agree with Dr. Negro that connection

between embolism in PFO and stroke or migraine-like aura

symptoms is strongly debated. Nevertheless, in case of

cryptogenetic TIA/stroke, PFO could be considered as a

source of cardioembolism, especially in an adult\50 years

with atrial septal aneurysm and spontaneous right-to-left

shunt. In our case, we indeed attribute the ischemic symp-

toms to SCAD, but, in the theoretical absence of SCAD, the

patient could have a supplementary pathogenetic factor.

The cornerstone of clinical management of patients

affected by MwA with the onset of a new headache is the

differential diagnosis to rule out a possible secondary ori-

gin, especially in the presence of neurological manifesta-

tions. In that case, the patient would be affected by a

‘‘multifactorial’’ headache. In our case, there were three

simultaneous possible causes of headache, which make the

differential diagnosis challenging.

We agree with Dr. Negro that the title of our case record

is formally inaccurate, but in our intention ‘‘multifactorial’’

is intended as provocative for a challenging case regarding

a patient with known MwA.

Conflict of interest None.

References

1. Negro A, D’Alonzo L, Martelletti P (2014) Framing comorbidities

and co-occurrences in a migraine with aura patient. Intern Emerg

Med. doi:10.1007/s11739-014-1079-2

L. Naldi � M. De Stefano � A. Berni (&) � M. Torri � L. Poggesi

Dipartimento di Medicina Sperimentale e Clinica, Universita di

Firenze, AOU Careggi, Florence, Italy

e-mail: berniandrea@inwind.it

123

Intern Emerg Med

DOI 10.1007/s11739-014-1088-1

2. Naldi L, De Stefano M, Berni A, Torri M, Poggesi L (2014) A

challenging multifactorial migraine with aura. Intern Emerg Med

9:201–205

3. Headache Classification Committee of the International Headache

Society (IHS) (2013) The international classification of headache

disorders, 3rd edn (beta version). Cephalalgia 33:629–808

4. Silbert PL, Mokri B, Schievink WI (1995) Headache and neck pain

in spontaneous internal carotid and vertebral artery dissections.

Neurology 45:1517–1522

5. von Babo M, De Marchis GM, Sarikaya H, Stapf C, Buffon F,

Fischer U, Heldner MR, Gralla J, Jung S, Simonetti BG, Mattle

HP, Baumgartner RW, Bousser MG, Arnold M (2013) Differences

and similarities between spontaneous dissections of the internal

carotid artery and the vertebral artery. Stroke 44:1537–1542

Intern Emerg Med

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