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General Rehabilitation

(Kiosk 1) Harrowing Headaches: What Do You Mean It’s Not Autonomic Dysreflexia?

Saturday, November 18, 2023
8:00 AM – 9:15 AM CT

    Primary Author(s)

  • Peter D. Vu, MD

    Resident Physician
    University of Texas Health Science Center At Houston PM&R Program
    Houston, Texas

    • Co-Author(s)

  • Charles Conselman, Other

    Medical Student
    University of Texas Health Science Center At Houston McGovern Medical School
    HOUSTON, Texas

  • IH

    Isaac Hernandez Jimenez, MD

    Associate Professor - UT Health Houston
    TIRR Memorial Hermann
    Houston, Texas

  • GF

    Gerard E. Francisco, MD

    Professor of PM&R and Chief Medical Officer
    UTHealth McGovern Medical School at Houston and TIRR Memorial Hermann
    Houston, Texas

Case Diagnosis: Status migrainous secondary to pituitary adenoma apoplexy in an SCI patient.

Case Description or Program Description: A 61-year-old C6 AIS-D man undergoing phase-two rehabilitation developed a headache on day 22. The patient had no history of migraines or headaches. He was continent of bowel and bladder, with occasional constipation requiring clean-outs. Additionally, scheduled midodrine was needed for hypotension. The headache was characterized as an acute, bilateral, throbbing occipital pain. Photophobia and phonophobia were present. Neurological exam was benign without evidence of diaphoresis or pallor. Autonomic dysreflexia and migraines were differentials; however, vitals were stable without hypertension, bladder scan was negative, clean-out was successful, clothes were loosened, and skin and nails were without lesions. Migraine cocktail was started with mild improvement. With no clinical improvement, a CT head found an expanding pituitary adenoma into the left suprasellar space without mass effect. Radiology reported this mass should not cause a migraine of this magnitude. Thus, the patient was transferred for an MRI, finding pituitary adenoma apoplexy. Neurosurgery provided abortive migraine medications and steroids. with resolution of symptoms. The patient continued therapies with neurosurgery follow-up planned.

Setting: Inpatient rehabilitation

Assessment/Results: Pituitary adenoma apoplexy can present similarly to AD

Discussion (relevance): This case highlights symptoms explainable by a myriad of diseases within SCI. However, status migrainosus via pituitary adenoma apoplexy in SCI is rare. Migraines in SCI patients are common, with a 200% increase in incidence compared to the general population. Headache in SCI patients is also concerning for AD, with 48-70% SCI patients with headaches as the first sign. Pituitary adenoma apoplexy presents similar to migraines and AD, including headache, photophobia, and phonophobia. Additionally, while hypotension is common in SCI, pituitary apoplexy has also been associated with hypotension.

Conclusions: While exceedingly rare, status migrainosus secondary to pituitary adenoma apoplexy should be considered for those that do not meet the criteria for autonomic dysreflexia.