Cough-induced hemiplegic migraine with impaired consciousness in cystic fibrosis.
The coughing paroxysms of patients with cystic fibrosis may occasion neurological symptoms. Although cough syncope is well-known, and is associated with headache and paralysis, a migrainous mechanism has not been reported. We reviewed the medical records, autonomic testing results, and responses to treatment in two cystic fibrosis patients with similar presentations of cough-induced impairment of consciousness followed by headache and paralysis. A 24-year-old woman and an unrelated 38-year-old man, both with cystic fibrosis, developed post-tussive neurologic deficits. Both patients reported infrequent dramatic spells, always preceded by major hemoptysis, and associated with left-sided paralysis, transient blindness, nausea, and severe pulsating headaches. Autonomic testing demonstrated only postural tachycardia and a near-vasodepressor episode in the woman, and mild, generalized sympathetic dysfunction in the man. Treatment for presumptive migraine with aura with verapamil nearly eradicated symptoms in both patients. Discontinuation of verapamil in the woman was associated with symptom recurrence and a stroke, with significant persistent residual left hemiparesis. In conclusion, cough-induced neurologic deficits were previously reported with cystic fibrosis, without clear understanding of the mechanism of impairment of consciousness. Based on the hemiparesis, nausea, and throbbing headache, which repeatedly followed the events in both patients, and based on the response to verapamil, we hypothesize a migrainous mechanism in both of our patients. The pathophysiology that links the hemoptysis to the spells deserves further investigation.
Rao
Dinesh S
DS
Department of Neurology, Case Western Reserve University School of Medicine and University Hospitals of Cleveland, Cleveland, Ohio, USA.
Infeld
Michael D
MD
Stern
Robert C
RC
Chelimsky
Thomas C
TC
D000328:Adult; D003244:Consciousness Disorders / Q000150:complications* / Q000523:psychology; D003371:Cough / Q000150:complications*; D003550:Cystic Fibrosis / Q000150:complications*; D005260:Female; D006429:Hemiplegia / Q000209:etiology* / Q000523:psychology; D006801:Humans; D008297:Male; D008881:Migraine Disorders / Q000209:etiology* / Q000523:psychology