Why Does This Happen
Generally speaking, misdiagnosis may happen because of findings on an MRI scan. For example, someone with migraine may have lesions that appear very similar to those associated with MS.
A 2013 study looked at people that received an MRI for a headache and had no previous history of a demyelinating disease like MS. After evaluating MRI scans from these individuals, it was found that 24.4 to 34.5 percent of the MRI scans met parts of the McDonald criteria for MS diagnosis.
Additionally, a doctor may also consider symptoms that are atypical for MS as a part of the diagnostic process, resulting in a misdiagnosis. This includes the symptoms of migraine.
While many people with MS may experience migraine, headache isnt typically one of the early signs of MS. Instead, symptoms to keep an eye out for include:
- muscle weakness, particularly in the hands or legs
Treatments are generally based on whats causing migraine. For example, if youve been prescribed fingolimod a disease-modifying therapy for MS and find that it triggers migraine attacks, your doctor might alter the dosage or prescribe a substitute.
Migraine medications are classified into two categories:
- Abortive medications help to ease the symptoms of an acute migraine attack.
- Preventive medications work to prevent migraine attacks from occurring.
A few examples of medications that can be used to either treat or prevent migraine in people with MS include:
How Do Lesions Correlate With Ms Symptoms
A lesion can interfere with the normal function of nerve cells, blocking or slowing normal electrical communication or nerve impulses in the brain and spinal cord. This can directly contribute to MS symptoms, with the specific effect depending on the location of the lesion.
However, not all lesions cause obvious symptoms. Sometimes patients can develop new lesions without associated disease manifestations these lesions are referred to as clinically silent. Conversely, patients may also have symptoms in the absence of a clearly detectable lesion in a corresponding part of the central nervous system.
Furthermore, it is not always possible to make a direct correlation between the location and number of lesions and the clinical signs and symptoms a patient experiences as part of disease progression.
Generally, according to the National MS Society, lesions in areas such as the spinal cord or optic nerve are likely to result in disease manifestations.
Can You Prevent Brain Lesions
Scientists are still looking for ways to protect against brain lesions. They think keeping your migraines in check can help. Having frequent attacks is linked with a higher risk of lesions, so fending off migraines or treating them early on may help lower your risk. These simple steps could help:
- Talk to your doctor. You may need to take medicine or get treatments, like Botox injections, to head off migraines.
- Know your triggers. Bright lights, weather changes, and certain foods could set off your migraines. Once you know your triggers, you can learn to avoid them.
- Keep a lid on stress. Make time to unwind and do things you enjoy every day.
- Get moving. Exercise eases tension and boosts blood flow to the brain, which can help stave off headaches. Research also shows that physical activity may prevent white matter lesions.
- Practice good sleep habits. A bad night could set off an attack. Try to go to bed and wake up at around the same time.
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Increased Contrast Enhancing Lesion Activity In Relapsingremitting Multiple Sclerosis Migraine Patientsmigraine And Contrast
We examined 509 MS and 64 CIS patients and 251 healthy individuals.
Subjects were assessed with 3 T MRI and for history of migraine.
More MS and CIS patients had migraine, compared to healthy controls.
More MS migraine patients presented with enhancing brain lesions compared to those without.
MS migraine patients had an increased number and volume of enhancing lesions.
Multiple Sclerosis Lesion: Definition
A lesion in multiple sclerosis is defined as an area of focal hyperintensity on a T2-weighted or a proton density -weighted sequence. Typical multiple sclerosis lesions are round to ovoid in shape and range from a few millimetres to more than one or two centimetres in diameter. Generally, they should be at least 3 mm in their long axis to satisfy diagnostic criteria, although the topography should also be taken into consideration, for instance, a lesion < 3 mm located in the floor of the fourth ventricle should be considered abnormal, as lesions and flow-related artefacts rarely occur in this location. Lesions should be visible on at least two consecutive slices to exclude artefacts or small hyperintensities, although in acquisitions with higher slice thickness , smaller lesions may be visible on a single slice.
Multiple sclerosis lesions typically develop in both hemispheres, but their distribution is often mildly asymmetric in the early stages. While lesions can occur in any CNS region, relative to other disorders that cause white matter lesions, multiple sclerosis lesions tend to affect specific white matter regions, such as the periventricular and juxtacortical white matter, the corpus callosum, infratentorial areas and the spinal cord . How involvement of these areas should be assessed to evaluate dissemination in space in patients with suspected multiple sclerosis will be discussed in the following sections.
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Migraine As A Symptom Of Ms
Some experts hypothesize that migraine may be an early symptom of MS, though there isn’t much evidence to support this theory.
A 2012 study found that women with migraines prior to their diagnosis of MS had a 39 percent higher risk of developing MS when compared to the participants without migraines.
Keep in mind, though, the study also showed that the actual chance of developing MS over a 15-year follow-up of the women was 0.47 percent for women with migraines and 0.32 percent for women without migraines. This means that, regardless of whether or not you have migraines, your chance of developing MS is still extremely small .
Focus On Symptoms Not Perceived Risks
Dr. Goadsby says patients are often concerned that brain changes correlate with stroke or cognitive dysfunction later in life. This is not the case, and Goadsby says in fact, the stroke risk for migraine sufferers become less prominent after the age of 45.
Patients with migraine with aura face a small risk of stroke compared to population controls , or patients with migraine without aura, he says. Because of the low risk, Goadsby says migraine patients who have regular normal physical examinations do not need to get regular brain scans. He says that the pain of migraine attacks is the symptom that patients and their care teams should prioritize, not the possibility of lesions or the fear of increased stroke risk. It should also be noted that the presence of these lesions should not influence the use of any particular medication.
Migraine is an inherited episodic brain disease, Goadsby says. It doesnt shorten life: it ruins it. Migraine patients do not have to be worried about long-term brain damage. It simply doesnt happen.
To learn more, visit the American Migraine Foundation, where neurologists like Dr. Goadsby and others share information and resources about the disease, including the various treatment options available to people living with migraine and head pain.
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Ms Treatment And Migraines
Several medications used to treat MS have been shown to exacerbate headaches, and migraines may be triggered by disease-modifying treatments, like the beta interferons and Gilenya® . People without a prior history of migraines who take disease-modifying treatments for their MS may develop headaches as a possible side effect of the treatment, but these usually improve over time as the body gets used to the treatment. For people who have a history of migraines, the treatments may be a trigger, just as they might experience triggers like certain foods, changes in the weather, or hormonal fluctuations .2
Do Migraines Cause Brain Lesions
Studies show that having migraines can make you more likely to get brain lesions. These painful headaches are linked to two main types of lesions:
- White matter lesions. White matter is tissue deep in the brain. Itâs made up of mostly nerves, and it plays a big role in your emotions. Getting small white matter lesions is a normal part of aging. Strokes, multiple sclerosis, and Alzheimerâs disease can also cause them. Because they show up on scans as bright white spots, theyâre sometimes called white matter hyperintensities.
- Infarct-like lesions. Your brain needs oxygen and nutrients. If blood flow is restricted or stopped, brain cells die. A small area of dead tissue is called an infarct. For people with migraines, these infarct-like lesions are silent, which means they donât have any symptoms. In older adults, these lesions are tied to the risk of dementia, but this doesnât seem to be the case in people who have migraines.
A review of studies found that people who got migraines were more likely to have white matter and infarct-like lesions than those who didnât. Those who got migraines with aura, or visual symptoms like blind spots, changes in vision, or flashes of light, had the biggest risk.
Getting frequent migraine attacks or a longer history of migraines also raises your chances of getting lesions. Women are more likely to get white matter lesions.
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Are White Matter Lesions A Suggestion That There Is Another Disease Process Than Plain Vanilla Migraine
The phenomenon of CADASIL points out that Migraine may not be one disease. As Migraine is a “committee diagnosis“, it may easily contain within it many distinct diseases, and furthermore, one diseases treatment might not work for another. Recent genetic studies in migraine would support this idea as well. It may be that there is a gene or group of genes, associated with headaches, that is responsible for white matter lesions. In the future, we may want to split up migraine into subvariants, one of which is migraine with white matter lesions. In our practice in Chicago, we often start with verapamil for prevention of migraine with white matter lesions.
Demographic Clinical And Structural Mri Characteristics
Table 1 summarizes the main demographic, clinical, and MRI structural characteristics of the patients. The two study groups were matched for gender, age, disability, and MS-related disease duration. The proportion of patients on MS disease modifying treatment as well as anxiety and depression symptoms severity were similar between groups .
Table 1. Main demographic, clinical, and structural MRI characteristics in MS+M and MS-M patients.
Also, no significant between-group difference was detected for normalized brain, GM, WM, overall T2 lesion volume, and spatial distribution .
MS+M patients had an average migraine disease duration of 4.5 years, six had migraine with aura who did not differ for demographic, clinical, and structural parameters with respect to patients without aura p = 0.74. The median HIT-6 score was 62 , MMD 6 days, and VAS-P score 7 . MMD was not significantly correlated with HIT-6 and VAS-P scores , whereas the HIT-6 scores were significantly correlated with VAS-P scores . No patient had any migraine attack the day following MRI.
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A Clinician’s Guide To Evaluating Brain Mri In A Patient With Improbable Multiple Sclerosis
Ilya Kister, MD, FAAN
Paraphrasing W.B. Matthews about dizziness, there can be few physicians so dedicated to their art that they do not experience a slight decline in spirits when they learn that a patients brain MRI shows nonspecific white matter T2-hyperintense lesions compatible with microvascular disease, demyelination, migraine, or other causes.1 The situation is particularly vexing if the patient with multiple nonspecific brain lesions also has multiple nonspecific sensory, vestibular, cognitive, and affective symptoms. Could this patient have multiple sclerosis , a potentially crippling, neuroinflammatory disorder characterized by diverse symptomatology and multiplicity of white matter lesions?
The Ms Lesion Checklist
The MS Lesion Checklist provides brief definitions for 10 types of lesions that are best appreciated on axial or sagittal T2-weighted and fluid-attenuated inversion recovery sequences. Typical examples are shown in Figures 1-8. Only lesions that conform to a description in The MS Lesion Checklist should be regarded as distinctly MS-like. For example, Dawsons fingers must be firmly in contact with the ventricles, as originally described by Dawson.3 Juxtacortical lesions, best seen on FLAIR sequences should be contiguous with cortex.4 MS brainstem lesions may be seen more clearly on T2W sequence than FLAIR and should only be considered distinctly MS-like if they border the subarachnoid space or a ventricle .5 MS corpus callosum lesions should border callososeptal interface on sagittal FLAIR as in Figure 7.
Figure 1. Nerve root entry zone lesion. Arrow: Lesion along left trigeminal root the trigeminal nerves are seen in the prepontine cisterns.
Figure 2. Cerebellar hemisphere lesions. Two small demyelinating lesions are seen in the right cerebellar hemisphere. Note there is also a typical peripheral brainstem lesion that appears to track along the left glossopharyngeal nerve root.
Figure 3. Middle cerebellar peduncle lesions. Bilateral middle cerebellar peduncle lesions as well as lesions within basilar pons and cerebellar hemispheres.
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Whats The Link Between Migraines And Brain Lesions
Experts arenât sure why migraines are linked with brain lesions. But these things may play a role:
- Blood clots and shortages. Migraine attacks may lower blood flow and pressure. They can also cause blood vessels to shrink. This sets the stage for tiny blood clots or a lack of blood to certain areas of the brain.
- Tissue damage. During a migraine, the nerves in your brain kind of go haywire. They may work overtime and become inflamed.
- Heart problems. Migraines are linked to two heart conditions: Patent foramen ovale is a hole in the heart. Mitral valve prolapse is when heart valves donât close fully, which may can cause a small leak. Both issues may lead to lesions.
Can You Have Ms Without Lesions
MS is defined by the presence of lesions in the central nervous system. The indicators used for making an early diagnosis are called the McDonald criteria. Under these formal guidelines, a person must show evidence of lesions that accrue over time and that affect at least two of four regions in the central nervous system three areas of the brain, and the spinal cord. The brain areas affected in MS are the periventricular, juxtacortical or cortical, and infratentorial. If a person does not meet these criteria, then the clinical case cannot be considered MS.
Usually, MS lesions are detected via imaging using MRI scans. It is possible for a person to have MS lesions that arent visible on these scans for example, some lesions may be too small to be seen. Under the current McDonald criteria, symptoms that are indicative of an MS lesion in a particular region of the nervous system may be used as evidence for a lesion in that region, but it is crucial to rule out other possible explanations for symptoms in such cases.
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What Do Ms Lesions Feel Like
Even though the central nervous system is packed with nerve cells, the brain tissue itself does not have so-called noniceptors the sensory nerve fibers that detect pain and potentially damaging stimuli. Thus, MS lesions themselves cannot be felt. Instead, they may induce symptoms that result from tissue damage to the nervous system.
The symptoms and signs of MS can vary depending on the particular location of the lesion. For example, a lesion in the optic nerves, which connect the eyes to the brain, can cause vision problems. Meanwhile, lesions in the spinal cord can cause unusual sensations such as tingling or numbness or motor symptoms, including loss of balance and/or coordination. Spinal cord lesions also may be associated with bladder and bowel impairments.
Lesions in the brainstem and cerebellum, toward the base of the brain, may cause symptoms that affect the face, including weakness, unusual sensation, double vision, and difficulty swallowing. Damage occurring toward the top of the brain, specifically the cortex and cerebrum, often does not cause obvious symptoms, though lesions in those areas may be associated with cognitive challenges and depression.
Migraines Versus Ms Lesions On The Optic Nerve
Some people with MS develop lesions on their optic nerve, which transmits signals from the eye to the brain. This is called optic neuritis , resulting in eye pain, as well as mild to severe vision loss and impaired color vision. Patients who have also experienced eye pain due to migraines might confuse the cause of this particular pain. Optic neuritis is the presenting symptom in 20% of MS patients, although it can occur without MS as well.2
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Can Ms Lesions Be Mistaken For Migraine Lesions
Migraine is a condition defined by periodic, severe headaches typically characterized by a throbbing or pulsing pain, nausea, and extreme sensitivity to lights and sounds. There are some similarities between migraine and MS, as both are chronic conditions affecting the nervous system, and both tend to be characterized by relapses or attacks times in which symptoms suddenly worsen.
People with migraine may have lesions in their brains resulting from white matter abnormalities, and these may appear similar to MS lesions on MRI scans. Thus, it can be difficult to distinguish between migraine and MS lesions, and there are many reports of people with migraine who initially received an incorrect diagnosis of a form of MS, or vice versa.
Further complicating matters, while headaches are not considered a typical symptom of MS, migraine and MS can co-occur in fact, research suggests that rates of migraine are two to three times higher among MS patients than in the general population. A review study published in 2020 estimated that roughly 30% of MS patients experience migraines.
According to the American Migraine Foundation, the MRI abnormalities seen in some patients may not even be considered lesions as they do not cause clear damage or disease-related signs it is believed that these abnormalities are generally not associated with any type of neurological issues or an increased risk of cognitive decline.