Migraine: A Chronic Sympathetic Nervous System Disorder

Stephen J. Peroutka


Headache. 2004;44(1) 

In This Article

Clinical Symptoms of Orthostatic Intolerance

As has been discussed previously, the simple act of standing from a supine position represents a sensitive test of ANS function. A coordinated series of sympathetic and parasympathetic nervous system reactions is required to counterbalance the effect of gravity on the vascular system. The autonomic system must maintain BP in order to assure the adequate perfusion on vital organs. If significant autonomic dysfunction exists, orthostatic hypotension is the most commonly recognized clinical sign. Much more subtle signs of autonomic, and especially sympathetic, nervous system dysfunction, however, can be elicited by orthostatic changes in position. These signs and symptoms can vary in severity and have recently been described as "orthostatic intolerance."

Orthostatic Symptoms in Individuals With Pure Autonomic Failure and Multiple System Atrophy. Clinical symptoms caused by or relating to orthostatic changes have been studied extensively in individuals with PAF and MSA, all of whom met criteria for orthostatic hypotension.[31] The most commonly reported clinical symptoms related to postural changes are listed in Table 2 . It has been suggested that the symptoms of dizziness, syncope, and visual disturbances are all related to cerebral hypoperfusion. The subocciptal/paracervical "coat hanger" pain, conversely, has been hypothesized to relate to hypoperfusion of the paracervical muscles.[2,3] Severity of neck pain appears to correlate with the degree of orthostatic hypotension.[32] In both PAF and MSA, all of these symptoms improve with lying flat or sitting. The symptoms tended to be worse in the morning, with warm temperatures, straining, exertion, and food ingestion.[2,3,32]

Orthostatic Symptoms in Migraineurs. Although significant orthostatic hypotension (as defined by BP alterations) is relatively rare in migraineurs, they do report similar frequent clinical symptoms that can be caused by orthostatic changes. For example, orthostatic symptoms such as dizziness and visual disturbances have been reported to be significantly more frequent in migraineurs than in controls,[33,34] and are also more prevalent in severe than in mild cases of migraine.[34] A number of large independent studies have analyzed many of the specific symptoms commonly found in patients with chronic sympathetic disorders.

Selby and Lance found that complaints of dizziness, lightheadedness, and unsteadiness, usually aggravated by stooping or rising, were reported by 94 (72%) of 131 patients analyzed.[15] A second independent study analyzed orthostatic symptoms and found them to be present in 40 (68%) of 59 migraineurs.[33] Therefore, in these 2 independent studies, 134 (70%) of 190 migraineurs reported lightheadedness or dizziness related to orthostatic changes.

Visual disturbances (defined as spots, flashes, and/or circles before the eyes as well as fortification spectra and various transient visual field defects) were reported by 184 (41%) of 448 patients with migraine.[15] It should be noted that simple blurred vision was felt to be too universal a symptom and was therefore excluded from this analysis. Scintillating scotomata, visual obscurations, or blurred vision was reported by 42 (72%) of 59 patients of Raskin and Knittle, of whom 8 (14%) of the 59 reported blurred vision.[33] In these 2 independent studies, 226 (45%) of 507 migraineurs reported visual disturbances as part of the migraine syndrome.

Neck pain in the subocciptal and paracervical muscles is a clinically well-recognized part of the migraine syndrome, although it has been poorly quantitated in the medical literature. Significant muscle and tendon tenderness occurs in the neck and shoulder muscles before, during, and after migraine attacks in many migraineurs.[35,36] In one study, neck or shoulder pain was reported in 23 (46%) of 50 individuals during a migraine attack.[35] In another study that inquired specifically about neck pain before, during, and after migraine attacks, 32 (64%) of 50 migraineurs reported neck pain or stiffness.[36] In a recent study based on a review of headache diaries from 97 migraineurs, a stiff neck was reported in 351 (63%) of 559 headache attacks.[37] Therefore, in these three independent published reports, neck pain or stiffness was present in 406 (62%) of the 659 migraineurs studied. A connection between sympathetic nervous system dysfunction and musculoskeletal pain has been hypothesized to relate to abnormal sympathetic activation of muscle spindles.[38]

Syncope is significantly more common in migraineurs than in nonmigraineurs,[16] yet only a few studies have measured its prevalence in migraineurs. Syncopal attacks in association with migraine were reported by 42 (11%) of 396 patients of Selby and Lance,[15] and in only 1 (2%) of the 59 patients of Raskin and Knittle.[33] Therefore, in these 2 independent studies, 43 (9%) of 455 migraineurs reported syncope as part of the migraine syndrome. This finding is in stark contrast to the frequency of syncope in individuals with PAF (91%) and MSA (45%) ( Table 2 ).[31]


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