Conference Coverage

Postural Tachycardia Syndrome Is Common Among Migraineurs


 

References

SAN FRANCISCO—Postural tachycardia syndrome (POTS), a disorder of orthostatic intolerance with neurocardiogenic syncope, is common among patients with migraine, according to an overview presented at the Eighth Annual Winter Conference of the Headache Cooperative of the Pacific. A patient presenting with headache and cognitive difficulty may have migraine, even if his or her medical and neurologic examinations are unremarkable. But additional symptoms such as postural lightheadedness, syncope, and postural tachycardia may indicate that the patient has orthostatic intolerance or POTS, “which is undoubtedly the most common autonomic disorder that we see,” said Brent P. Goodman, MD, Assistant Professor of Neurology at Mayo Clinic Arizona in Scottsdale.

The number of Americans with POTS may be more than 500,000, said Dr. Goodman. About five females have POTS for every male with the disorder, and onset usually occurs between the early teens and the mid 40s.

Joint hypermobility is “probably the single biggest risk factor for POTS,” said Dr. Goodman. POTS results from a preceding infection in 30% to 40% of patients. Onset also can occur during or following pregnancy, after a medical procedure, and following concussion. Deconditioning is a risk factor and may worsen symptoms, but no reproducible studies to date have associated any genes with the disorder.

The Relationship Between Migraine and POTS
POTS and migraine often are comorbid disorders. In a retrospective review of a large series of patients, researchers from the Mayo Clinic in Arizona found that approximately 28% of people with POTS have migraine. In a prospective study of 24 participants with symptoms suggestive of orthostatic intolerance, 23 had migraine. Approximately 60% of participants with headache had a postural component to the headache. Additional studies are necessary to determine whether headache or migraine characteristics correlate with various autonomic signs, symptoms, or findings on autonomic testing.

Thijs and colleagues found that the lifetime prevalence of syncope among migraineurs was 46%. This prevalence “was significantly increased, relative to controls, suggesting that patients with migraine may be predisposed to having symptoms of orthostatic intolerance,” said Dr. Goodman. People with a history of migraine had a much higher prevalence of recurrent syncope, compared with controls. Furthermore, symptoms suggestive of orthostatic intolerance were more common among migraineurs than among controls.

The Path to a Diagnosis of POTS
Syncope can indicate that the patient has an autonomic disorder, particularly if it occurs with standing or exertion. Syncope that occurs in the morning, in the heat, or following the administration of medications that reduce blood pressure also may indicate the presence of an autonomic disorder. Other potentially telling symptoms include postural lightheadedness, dizziness, gastrointestinal symptoms such as constipation and diarrhea, and frequent urination.

For a neurologist to diagnose POTS, he or she must rule out orthostatic hypotension and conditions that cause it. In addition, the patient’s heart rate must increase by 30 bpm, or the heart rate must be greater than 120 bpm, within 10 minutes of standing upright.

POTS rarely results from an identifiable secondary cause, and certain conditions may mimic POTS. Celiac disease, Sjögren syndrome, and systemic lupus erythematosus may be associated with symptoms of orthostatic intolerance. Neurologists also should consider mastocytosis or mast cell activation disorders as a possible diagnosis because patients with mastocytosis may complain of orthostatic intolerance, headache, and flushing.

To evaluate a patient with suspected orthostatic intolerance, a neurologist should confirm that his or her heart is structurally and electrically normal, and also rule out secondary causes and mimickers. Chest radiograph, EKG, and Holter monitoring should be considered. The best way to confirm a diagnosis of POTS is the tilt-table study, said Dr. Goodman. Checking orthostatic vital signs is “probably not as sensitive” a measure, he added.

Nonpharmacologic Treatments Are Effective
Nonpharmacologic measures are the most appropriate form of initial management of a patient with POTS. “The most important things are to liberalize salt and fluid intake and encourage [the patient] to engage in exercise,” said Dr. Goodman. Patients should consume 10 g/day of salt and drink 2.5 L/day of fluid. Half of the fluid should contain electrolytes.

Tilting the head of the bed up by four to six inches often helps patients. Physicians should recommend that the patient wear compression stockings and an abdominal binder to reduce the amount of blood that pools in the legs and abdomen. Daily isometric exercises to strengthen the leg and abdominal muscles also can reduce venous pooling. Cardiovascular exercise is recommended as well.

Pharmacotherapy may be advisable for some patients. Midodrine is an appropriate first-line medication, said Dr. Goodman. Its primary side effect is scalp itching. Fludrocortisone, which expands blood volume, is a good choice for patients with gastrointestinal symptoms who have difficulty achieving an adequate intake of salt and fluid, he added.

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