SEARCH

SEARCH BY CITATION

Keywords:

  • headache;
  • posttraumatic migraine

Abstract

  1. Top of page
  2. Abstract
  3. CASE HISTORY
  4. COMMENTS
  5. REFERENCES

A 28-year-old woman presented with severe headache, sleep problems, memory problems, and irritability 2 months after a violent roller coaster ride. She was diagnosed with posttraumatic migraine, and intravenous dihydroergotamine resolved her symptoms. Imaging studies, electroencephalogram, and visual and auditory evoked responses were normal. Imipramine, divalproex sodium, and propranolol were prescribed to prevent the headaches from recurring and dihydroergotamine nasal spray was prescribed for breakthrough headaches. We consider the many short but significant brain insults delivered during the roller coaster ride a critical factor in triggering this instance of posttraumatic migraine, which while unmanaged was a source of significant disability for the patient.


Abbreviations:
DHE

dihydroergotamine

CASE HISTORY

  1. Top of page
  2. Abstract
  3. CASE HISTORY
  4. COMMENTS
  5. REFERENCES

A 28-year-old woman presented with severe headache, sleep problems, memory problems, and irritability 2 months after a roller coaster ride at a nearby amusement park. Reaching a top speed of 62 miles per hour with drops of as much as 137 feet, the ride was punctuated by violent shaking back and forth. The patient described being held firmly in the carriage seat by braces that allowed her head to bobble vigorously and uncontrollably during the ride. She reported difficulty getting up after the ride because she was dizzy and “things seemed to be spinning a bit.” Within minutes, she developed throbbing headache, blurred vision, and nausea. Her symptoms persisted for approximately 1 hour, and she visited a nearby emergency department. Brain computed tomography (CT) scan and cervical spine x-rays were normal.

For 2 months, she continued to have at least two headaches a week. She took analgesic medication with slight relief. The headaches began with bilateral throbbing pain followed by visual blurring, nausea, and vomiting, which generally lasted 3 to 4 hours; these symptoms required her to be absent from work. On other days, the headache was less bothersome, and she only noted neck muscle tenderness. She also reported restlessness and difficulty sleeping. Her chief complaint on presentation was headache.

Neurological examination revealed no mental status deficits. Visual fields, fundi, and eye movements were normal. She had no facial weakness, and her lower cranial nerves functioned normally. Reflex, gait, posture, muscle tone, strength, and sensory examinations were also normal.

Diagnosed with posttraumatic migraine, she was hospitalized overnight and given 0.5 cc intravenous dihydroergotamine (DHE) every 8 hours. This relieved the headache, and the patient said she was much more comfortable and had better concentration. Magnetic resonance (MR) scan and MR angiogram of the brain were normal. Electroencephalogram as well as visual and auditory evoked responses were normal. Imipramine (50 or 100 mg at night), divalproex sodium (250 mg twice a day), and propranolol (20 mg twice a day) were prescribed to prevent the headaches from recurring. Dihydroergotamine nasal spray was also prescribed for breakthrough headaches, which occurred if she missed her medication, became overly fatigued, or experienced unusual stress. At no time during treatment were her complaints inconsistent. Her description of drug responses was accurate, and her compliance with medication was good. She was unconcerned about litigation and continued working despite demonstrated difficulties.

COMMENTS

  1. Top of page
  2. Abstract
  3. CASE HISTORY
  4. COMMENTS
  5. REFERENCES

It is well known that minor head trauma can produce migraine. With increased awareness and more careful evaluation of patients, more causes of posttraumatic migraine are being recognized. In 1944, Brenner et al published a major article on posttraumatic migraine that cited references reporting the frequency of posttraumatic migraine at 28%, 33%, 42%, 50%, and 80%. 1 The authors stated that posttraumatic migraine could be accompanied by features of posttraumatic syndrome, such as memory problems, dizziness, anxiety, and sleep disturbance. They emphasized that minor trauma could cause chronic headaches and could aggravate migraine in susceptible individuals.

In 1991, Weiss et al reported their experience with 35 adults with posttraumatic migraine. 2 This group of 27 women and 8 men had no prior history of headache. Fourteen had experienced minor head trauma with a brief loss of consciousness, 14 had minor head trauma with no loss of consciousness, and 7 had whiplash neck injuries without head trauma. The persistence of headache was noted, and the need for ongoing treatment was emphasized.

In 1986, Jacome reported four patients with basilar artery migraine who demonstrated nausea, vomiting, vertigo, blurred vision, and syncopal feelings. 3 All patients reported typical whiplash concussion-type minor head trauma with no prior headache history.

Solomon, in his John Graham Award lecture of June 20, 1997, described posttraumatic migraine as a common and important consequence of minor head trauma and suggested that it may be more common than most believe. 4 He stated that several situations “warrant the term posttraumatic migraine.”4 He cautioned that trauma may be the only precipitating event, such as “footballer's migraine” suffered by soccer players. 5 Solomon also stressed that trauma may trigger a first attack, but may not necessarily be a major factor in future attacks. He noted that individuals who are genetically susceptible to headache are more frequently afflicted with this disorder than those who are not.

Our literature search produced no reports of roller coaster-related migraine, but we noted three reports of roller coaster-related neurovascular injury. In 1994, Fernandes and Daya reported a 26-year-old, right-handed student who presented with headaches following a roller coaster ride and was found to have subdural hematoma formation, particularly on the left. 6

In 1995, Bo-Abbas and Bolton reported a 64-year-old man who rode a roller coaster multiple times despite a persistent headache and developed a left-sided hematoma with mass effect. 7 Also of interest is a report by Scheer and Carlin in 1979 of a strokelike episode following carotid compression during a roller coaster ride. 8 Recently, Fukatake et al reported the case of a patient who developed headache and bilateral chronic subdural hematomas after a series of roller coaster rides. 9

Migraine generation is a complex process thought to begin with neural events that are rapidly accompanied by various vascular and trigeminal vascular events. Most consider the median (dorsal) raphe nuclei in the brain stem the primary migraine generator. Goadsby et al demonstrated that these neurons affect cerebral circulation in the carotid tree 10 and that they are a site of DHE localization. 11 He also noted localization of DHE in the nucleus caudalis at the C2 end of the descending trigeminal root. 12 This may be instrumental in triggering the many prominent events of the trigeminal vascular system during migraine attacks. 13 In fact, many migraine attacks begin with pain or tension in the neck and can be successfully aborted with medications such as DHE and sumatriptan if taken at the onset of symptoms.

Our patient was subjected to a number of brief, rapid, and violent whiplash-type movements of the head and neck during the roller coaster ride. One can speculate that numerous brief insults were delivered to the brain. In addition to repeated direct lines of force to the brain, lines of force involved the neck as it was jerked around in a whiplash fashion. We consider the many brief significant insults delivered to the neck and brain of our patient during this 2-minute roller coaster ride the major factor in triggering this instance of posttraumatic migraine, which while unmanaged was a source of major disability for the patient.

This case is of particular interest considering the many recent media reports detailing roller coaster injuries.

REFERENCES

  1. Top of page
  2. Abstract
  3. CASE HISTORY
  4. COMMENTS
  5. REFERENCES