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Estrogens and migraine.

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LETTERS
Recovery Following
Brainstem Hemorrhage
J. M. Vallat, MD, C. Poumier, MD,
D. Demarti, MD, and M. Dumas, M D
W e have recently observed three normotensive patients
with brainstem hemorrhage. T h e diagnosis was confirmed
by C T scan. Vertebral arteriography showed no aneurysm
nor arteriovenous malformations.
Two patients, 4 and 34 years old, respectively, completely recovered without surgical intervention. T h e hemorrhage was located on the lateral side of the pons. Regression of the hemorrhage was confirmed by serial C T scan.
The third patient, a 48-year-old woman, showed bleeding
involving the left mesencephalon without associated hydrocephalus. D u e to insidious onset of neurological deficits, as has occasionally been reported [2], and incomplete
regression shown by successive C T scans, stereotaxic exploration of the lesion was carried out in Prof Talairach’s
unit. Small samples taken confirmed the presence of blood
associated with a very small vascular malformation, which
could correspond to capillary telangiectasis. No hematoma
was drained. With corticosteroid therapy the symptoms
slowly regressed. O n e year after the onset of the clinical
manifestations, the patient had no neurological defect.
As noted by Burns et a1 [l], most cases of apparently
primary brainstem hemorrhage probably result from cryptic vascular malformations. Although C T scan is helpful,
stereotaxic diagnostic exploration, which is generally safe,
may prove useful when the diagnosis is uncertain.
Department of Neurology
C. H . U . Dupuytren
87 031 Limoges Cedex, France
References
1. Burns J, Lisak R, Schut L, Silberberg D: Recovery following
brainstem hemorrhage. Ann Neurol 7:183-184, 1980
2. Stahl SM, Johnson KL, Malamud N: The clinical and patho-
logical spectrum of brain-stem vascular malformations. Arch
Neurol 37:25-29, 1980
Estrogens and Migraine
language disturbances occurred during the headache
period. Four months later, stilbestrol was discontinued
and the headaches improved. After one week free of
headaches, stilbestrol was restarted and similar headaches
promptly recurred. Stilbestrol was again discontinued and
the headaches immediately improved. O n e month later the
patient was free from headache and has since remained so.
Between the periods of headache, neurological examination was normal; but once, during a headache, a left visual
field defect was noted. Later the same day, after the episode
subsided, vision returned to normal. Radiological and laboratory evaluations were normal except for platelet aggregation studies, which revealed an abnormal ratio of circulating platelet aggregates of 0.72. Past history was remarkable
for recurrent nonincapacitating bifrontal headaches associated with nausea and diarrhea. In recent years they had become infrequent.
Our patient had a history of moderate common migraine,
but after estrogen medication was started his symptoms became those of a severe classic migraine. T h e relationship
between drug and symptoms appears credible given the
improvement that followed withdrawal of the drug, on two
occasions, and the recurrence of episodes upon reinstitution of the drug. A relationship between migraine and estrogens has previously been demonstrated: menstrual
migraine is triggered by the sudden drop in circulating estrogen levels [ 51; in women taking contraceptives, migraine
headaches usually worsen during “off” periods (or during
the week prior to the menstrual period in women who use
sequential preparations) [4].The fall in estrogen level supposedly acts o n cranial vasculature in much the same manner as it is known to act on uterine vessels.
O u r case raises the possibility that the relation between
estrogens and migraine is not limited to a fall in estrogen
blood levels-steady or rising levels of estrogens possibly
produce a similar effect. The continuous action of estrogens may not only change vascular permeability and reactivity but also, by modifying platelet aggregation, contribute to an increase in migraine attacks and even turn a
common migraine syndrome into one of classic migraine.
This case also suggests that the effect of estrogens in migraine is not necessarily conditioned by a sex-related vascular reactivity.
The Migraine Clinic
Department of Neurology
University of Iowa College of Medicine
Iowa City, IA 52242
Hanna Damasio, MD, and James J. Corbett, M D
Estrogens, given for birth control or menopausal syndrome, have been associated with worsening of migraine
headaches [l-41. The following report suggests that the
same may be true in the male migrainous patient, in whom
estrogens are rarely used.
A 75-year-old white man had surgery for prostatic carcinoma and was started o n stilbestrol, 5 m g daily. O n e
week later he began to experience severe bifrontal, throbbing headaches with nausea and occasional vomiting. T h e
headaches lasted 4 to 6 hours and appeared three o r four
times weekly. Fortification spectra in both visual fields and
92
References
1. Carroll JD: Migraine and oral contraception. In Proceedings of
the International Headache Symposium. Basel, Sandoz, 197 1,
pp 45-49
2. Dennerstein L, Laby B, Burrows GD, Hyman GJ: Headache
and sex hormone therapy. Headache 18:146-153, 1978
3. Kudrow L The relationship of headache frequency to hormone
use in migraine. Headache 15:36-40, 1975
4. Ryan RE: A controlled study of the effect of oral contraceptives
o n migraine. Headache 17:250-252, 1978
5. Somrnerville B: Estrogen-withdrawal migraine. Neurology
(Minneap) 25:239-244, 245-250, 1975
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