Can migraines cause multiple periventricular and juxtacortical micro-lesions?

Migraine as a Cause of Periventricular and Juxtacortical Micro-lesions

Migraine can cause periventricular and juxtacortical micro-lesions, but the pattern and characteristics of these lesions differ significantly from those seen in multiple sclerosis and should raise suspicion for MS when they exceed certain thresholds or display specific features.

Prevalence and Characteristics of Migraine-Related Lesions

• Up to 30% of migraine patients can have periventricular lesions 1
• Migraine-related lesions have distinct characteristics:
  • Periventricular lesions typically do not directly abut the ventricles
  • They are not oriented perpendicular to the ventricles
  • They lack the "Dawson's fingers" appearance characteristic of MS lesions 1
  • They are usually small and punctate in appearance 1

Juxtacortical Lesions in Migraine

• Juxtacortical lesions in migraine patients are typically separated from the cortex by a rim of normal white matter, unlike MS lesions which directly abut the cortex 1
• These lesions are frequently found in migraine patients (55.1% of migraine patients vs 22.2% of healthy controls) 2
• Right-to-left shunts have been independently associated with juxtacortical spots on FLAIR images in migraine patients 2

Distinguishing Migraine Lesions from MS Lesions

Key Differentiating Features

• Number of periventricular lesions: The presence of ≥3 periventricular lesions that directly abut the ventricles should raise suspicion for MS rather than migraine 3, 1
• Lesion orientation: MS lesions are characteristically ovoid and perpendicular to ventricles (Dawson's fingers), while migraine lesions lack this pattern 3
• Lesion location: MS lesions commonly involve the corpus callosum, infratentorial regions, and spinal cord, whereas migraine lesions are more commonly found in deep white matter 1

Red Flags Suggesting Alternative Diagnoses

When evaluating white matter lesions in migraine patients, consider other potential diagnoses such as:

• CADASIL: Suspect when lesions involve the anterior temporal pole, external capsule, basal ganglia, and/or pons 1, 4
• Multiple Sclerosis: Consider when finding ≥3 periventricular lesions, especially with Dawson's fingers appearance, or lesions in the corpus callosum and infratentorial regions 3

Risk Factors and Clinical Implications

• Women with migraine have an increased risk for deep white matter lesion load compared to controls (OR 2.1) 5
• The risk increases with attack frequency (OR 2.6 for those with ≥1 attack per month) 5
• Migraine with aura is associated with a higher prevalence of posterior circulation territory infarcts, particularly in the cerebellum (OR 13.7) 5

Imaging Considerations

• Synthetic T2-FLAIR and Synthetic DIR sequences can detect more white matter hyperintensities in migraine patients compared to conventional T2-FLAIR, especially in deep and juxtacortical white matter areas 6
• Lesions in subcortical regions substantially contribute to lesion burden in MS but are less likely to show gadolinium enhancement compared to lesions in diagnostic regions (periventricular, juxtacortical, infratentorial) 7

Conclusion

While migraine is associated with white matter lesions, the pattern and characteristics of these lesions differ from those seen in MS. The presence of multiple (≥3) periventricular lesions that directly abut the ventricles, lesions with Dawson's fingers appearance, or lesions in specific locations like the corpus callosum should prompt consideration of alternative diagnoses, particularly MS.