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Summary and conclusionMigraine is a common, chronic, multifactorial neurovascular disorder typically characterized by recurrent attacks of disabling headache and autonomic nervous system dysfunction. Migraine is a painful and disabling disorder that imposes substantial burden on individual sufferers and society as a whole.The present study was carried out to clarify hemodynamic changes in the cerebral blood vessels by transcranial Doppler (TCD) as well as probable structural brain lesions using magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) in young adult migraineurs.The included subjects of our study were divided into two groups: Patients group [Group I]:Forty migraineous patients were selected; 32 females (80%) and 8 males (20%); fulfilling the International Headache Society (IHS) diagnostic criteria for migraine. Age of patients was selected to be ranged from 20- 40 years with mean age of 32.48 ± 6.19 years.Patients were further classified into 2 subgroups: Group 1a: Migraine without aura (26 patients). Group 1b: Migraine with aura (14 patients). Control group [Group II].Twenty age and sex matched normal volunteers; 13 females and 7 males; were included with mean age 31.75±5.68 years.The included patients were subjected to the following:1) Full history taking with special stress on history of headache.2) The Migraine Disability Assessment Score (MIDAS).3) Thorough general and neurological assessment.4) Laboratory investigations including:a) Complete blood count (CBC).b) Fasting blood sugar.c) Kidney function tests.d) Liver function tests.e) Erythrocyte sedimentation rate (ESR).f) Others: selected according to the clinical condition of every case.5) Transcranial Doppler Ultrasonography.6) Magnetic Resonance Imaging.7) Magnetic Resonance Angiography.Our study revealed :Clinical results:-The number of females suffering from migraine were predominant than males especially those with aura (92.9%) than those without aura (73.1%) but without a statistically significant difference.-Thirteen patients in our study (32.5%) experience bilateral pain.-The percentage of female migraineurs in our study who were oral contraceptives (OCs) users was 56.3%. Of whom 69.2% had migraine with aura, while 26.3% suffered from migraine without aura with statistically significant differences.-Positive family history was recorded in 14 (35%) of our patients.-The mean Migraine Disability Score was 12.2 ± 5.4. Regarding score grading of our patients, (37.5%) of them were in the moderate disability group.Results of TCD:- Transcranial Doppler (TCD) revealed a highly statistical significant increase in the blood flow velocity in all recorded vessels in all migraineurs inbetween attacks compared with the control group. Furthermore, the same results were found between migraine without aura in relation to controls, and migraine with aura in relation to controls-There was a non significant increase in pulsatility index (PI) in migrainous patients during the headache – free period compared to controls, and also in migraine without aura patients in relation to those with aura.- A moderate although not statistically significant reduction in mean flow velocity (MFV) in both sides during attack was detected in relation to those inbetween attacks.- Mean flow velocity in migraine with aura group was non significantly higher than those without aura group.- Patients with unilateral migrainous attack had non-significant higher MFV on the affected side compared to the non-affected side in the headache-free period.- Non-statistically significant reduction in both systolic and diastolic velocities and increasing in PI were recorded in migrainous patients during the attack.Results of MRI:- Fourteen (35%) of our 40 patients had white matter hyperintense (WMH) foci in MRI, which were higher in patients with aura (42.9%) than in those without aura (30.8%).- White matter hyperintense foci were detected more in female patients (37.5%) than male (25%).- Eight patients (57.1%) out of 14 migraine patients with WMH foci in our study, had bilateral lesions- As regards the grade of severity of periventricular (PV) and deep white matter lesions, we found that migraine patients with aura had more severe grading (3-6) (75%) than migraine patients without aura (12.5%).Results of MRA:- There was mild spasm affecting intracranial carotid arteries in 5 (12.5%) migraine patients. The most common affected artery was MCA, followed by PCA and ACA.Correlation results:- Regarding the correlation between the TCD parameters and clinical data of our patients, we found a significant inverse correlation between age and blood flow velocities of middle cerebral artery.- As regards the correlations between the presence of WMH foci and clinical parameters of our patients, the only significant correlation was detected with the frequency of migrainous attacks.- In our study, regarding the relation between TCD and MRA findings, there were increase in MFV in patients with spasm in MRA in relation to those without spasm.- There was good agreement between the results of MRI and MRA imaging studies in the evaluation of migrainous patients. All patients with spasm in MRA imaging have WMLs in MRI studies.- As regards sensitivity and specificity of each investigation, (TCD, MRI, MRA) in our patients; the sensitivity was 60% in TCD, 35% in MRI, and 12.5% in MRA. On the other hand, specificity was 100% in both MRI and MRA, and 95% in TCD.Conclusion:The International Headache Society (IHS) classification and diagnostic criteria for migraine are proved to be valid, reliable, and comprehensive diagnostic tool. Patients fulfilling these criteria rarely need additional diagnostic testing except for certain circumstances for which testing is necessary; such as; prolonged aura, increasing frequency, severity, usage of OCs, and positive family history of migraine.While TCD is a functional neuroimaging that detect transient hemodynamic changes, MRI is a structural neuroimaging that detect permanent intracranial lesions. Thus we may conclude that TCD is an established method to diagnose hemodynamically significant spasm in major intracranial arteries in migrainous patients. On the other hand, the ultimate goal in diagnostic brain imaging procedures (MRI, MRA) is the identification of brain lesions, its site, extent, and type for best management of the case.The noninvasiveness of TCD and the possibility it provides for obtaining instantaneous information about cerebral blood flow changes indicates its usefulness in the study of vascular changes in different types of migraine.Recommendations:Although investigations are usually not indicated for the diagnosis of migraine, there are number of circumstances for which testing is recommended; namely; migraine with aura, increasing frequency, severity, current or past use of OCs, positive family history of migraine.Young adults with primary uncomplicated migraine are vulnerable to occurrence of white matter hyperintense lesions. Based on our finding of significant correlation of WMLs in MRI and frequency of migrainous attack, it is necessary to assess whether prevention or early abortion of the attack will also decrease the risk for brain lesions and whether there is a subgroup most likely to benefit.
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