COMPLICATED MIGRAINE-LIKE EPISODES IN CHILDREN FOLLOWING CRANIAL IRRADIATION AND CHEMOTHERAPY

Neurologic sequelae may occur months to years after cranial irradiatio n. The site of primary damage is probably the vascular endothelium. Ov er a 2.8-year period, four children with brain tumors, a mean of 11 ye ars of age at diagnosis (range, 6.5 to 15.5 years), had new onset of s evere intermittent unilateral headaches associated with nausea, episod ic visual loss, hemiparesis, aphasia, or hemisensory loss. The headach es lasted 2 to 24 hours. All patients had previously received whole-br ain (2,400 to 3,600 cGy) and additional local boost (1,800 to 3,100 cG y) cranial irradiation, as well as cisplatin-, lomustine-, and vineris tine-containing chemotherapy regimens. Symptoms began 1.2 to 2.8 years after the diagnosis, when all had stable disease and were off treatme nt. MRI studies were unchanged, and CSF cytology, EEGs, echocardiogram s, and magnetic resonance angiograms were normal in all. Cerebral angi ograms, performed in three children, were normal but led to severe hea daches and neurologic deficits (hemiparesis in one and visual loss in two) that resolved after 24 to 48 hours. Response to antimigraine and antiplatelet medications was variable. We conclude that (1) ''complica ted migraine-like episodes'' may occur in children after cranial irrad iation and chemotherapy as a sequela of therapy; (2) these headaches m ay not be the harbinger of impending strokes, severe intracranial vasc ulitis, or tumor recurrence; and (3) while cerebral angiography may be useful in differential diagnosis, it may cause transient worsening of symptoms.