Objective: To describe dystonia phenomenology and preliminary pain response to toxin therapy in a single-center migraine cohort.

Background: The co-existence of headache and craniocervical dystonia (CCD) and treatment response with botulinum toxin A (BoTNA) were described in seven studies. Of the reported 380 subjects, 84 had comorbid CCD and migraine and demonstrated improvement with BoTNA. Emphasis was placed on describing headache location and characteristics with only 16 of the 380 subjects described as having a “no-no” dystonic tremor.  Here we describe dystonia phenomenology and preliminary toxin response in a migraine cohort.

Method: Partial retrospective chart review of migraine patients referred to movement disorders center for evaluation of co-existing, untreated dystonia.  Described phenomenology and quantified dystonia severity with TWSTRS. Prospectively following clinical response to dystonia treatment and report preliminary findings.

Results: All 31 migraine patients had CD (27 females, 4 males, mean age 49.4, SD 13.4); 29 developed migraines first.  Nineteen of 29 (65.5%) developed migraines prior to CD by a mean of 10.8 years (SD 11.6). All had laterocollis and 17 had torticollis. Twenty-five (81%) had isolated CD and 6 (19%) had segmental dystonia (one Meige, five neck and arm dystonia). Eight had head tremor (26%). Only 11 (35%) reported headaches ipsilateral to dystonia. In 25 (81%), CD pain triggered migraines. TWSTRS Severity Scale section scores ranged from 12/35 to 24/35 at baseline. Twenty-nine received individualized BoTNA treatments based on symptoms.  Five TWSTRS at six months follow up demonstrated: improvement (3); unchanged (1); worsening (1). Two of three who improved noted a decrease in headache severity but not frequency.

Conclusion: This single-center cohort of migraine patients with CD suggests: migraine commonly precedes CD development; isolated CD is the most common form of dystonia; laterocollis was the most frequent CD phenotype; dystonic head tremor is uncommon; and CD may be an important trigger for migraine worsening.  Few experienced headaches ipsilateral to the dystonia thus making early diagnosis of CD in these patients challenging. Further studies are needed to confirm our results.  Neurologists who care for these patients should be aware of this co-morbidity and treat accordingly for better patient outcomes.

References: 1. Bezerra, M. E. and Rocha‐Filho, P. A. (2017), Headache Attributed to Craniocervical Dystonia – A Little Known Headache. Headache: The Journal of Head and Face Pain, 57: 336-343. doi:10.1111/head.12996 2. Hulzenga, M. A., Beumer, D., and Koehler, P. J. (2017). Dystonic Head Tremor and the Coexistence of Headache. Tremor and other hyperkinetic movements (New York, N.Y.), 7, 485. doi:10.7916/D8BR94Q6 3. Winner, P. K., Sadowsky, C. H., Martinez, W. C., Zuniga, J. A. and Poulette, A. (2012), Concurrent OnabotulinumtoxinA Treatment of Cervical Dystonia and Concomitant Migraine. Headache: The Journal of Head and Face Pain, 52: 1219-1225. doi:10.1111/j.1526-4610.2012.02164.x

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MDS Abstracts - https://www.mdsabstracts.org/abstract/describing-dystonia-phenomenology-and-preliminary-treatment-response-in-migraine-patients/