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Acute aseptic meningitis inducing migraine‐like attacks in a 7‐year‐old child

Sir, A 7-year-old boy was referred to us for attacks of headache and fever for 5 days. Attacks occurred twice per day and lasted 2–5 h. The pain was very severe and he had a throbbing sensation, constantly localized in the right temporal region, extending to the eye and posterior areas. Pain was associated with fatigue, photophobia, nausea and vomiting. He reported occasional tactile and thermodolorific hypoesthesia in the left hemisoma few minutes before the onset of headache. Previously, the child had presented sporadic headache attacks characterized by dull frontal bilateral pain. His mother and his aunt suffered from migraine with aura. At our first observation, the child complained of severe headache, and his body temperature was 37.4 C. Neurological examination was normal; mild neck stiffness was present. Blood count, biochemical examinations, erythrocyte sedimentation rate, computed tomography, magnetic resonance imaging and electroencephalogram recordings were normal. Cerebrospinal fluid (CSF) examination showed: 113 cells (mostly lymphocytes); glucose 1⁄4 55 mg/dl; proteins 1⁄4 110 mg/dl; CSF antibody titres, cultures for bacteria, viruses, fungi and tuberculosis were negative. The following night, he presented acute throbbing pain, fever and vomiting. Neurological examination revealed rigor nucalis, left tactile and thermo-dolorific hypoesthesia extended to the midline, allodynia in right frontal and periorbital areas and the right forearm. A second CSF examination showed: 180 cells; glucose 1⁄4 40 mg/dl; proteins 1⁄4 72 mg/dl. Polymerase chain reactions for Herpes and non-polio enteroviruses were negative. Paracetamol induced partial relief. The acute attack and the neurological signs ceased after 4 h. Headache episodes persisted for 3 days and then ceased. In the following year, the boy reported no headache. All the above-mentioned symptoms fulfil the criteria for acute aseptic meningitis [1]. The International classification of headache disorders (ICHD)-II (point 7.3.2) defines, a headache associated to aseptic (non-infectious) meningitis [2]. This diagnosis can be excluded, because the child never took any drug. Our patient presented a series of migraine-like headache attacks. Migraine-like attacks associated with CSF abnormalities have been reported [3–7]. The ICHD-II defines this condition as syndrome of transient headache and neurological deficits with CSF lymphocytosis (HaNDL) . Gomez-Aranda et al.[6] reported, in a series of 50 patients, that pain localization in HaNDL is more often bilateral, and that meningeal irritation signs are always absent. Morover, all the patients reported in their study were >14 years of age. Nevertheless, this case fulfils the ICHD-II criteria for HaNDL, making this the first report of HaNDL in a child. Alternatively, we speculate that acute aseptic meningitis may have acted as a trigger for a series of migraine-like attacks. Some observations support this hypothesis: the distribution and relapsing– remitting course of pain; the presence of transient focal neurological deficit and the presence of allodynia. Allodynia reflects the hyperexcitability of central pathways and the activation of the trigemino-vascular system in response to stimuli [8]. Landy et al.[9] proposed that allodynia is a symptom of migraine, with a potential role in directing optimal treatment for migraine attacks . Sterile neurogenic inflammation has been proposed as one of the basic pathogenetic mechanisms of migraine [10]. Acute aseptic meningeal inflammation may have induced migrainelike attacks in a predisposed subject. In conclusion, we describe a child affected by a peculiar acute headache syndrome, associated with CSF abnormalities, which can be diagnosed as a juvenile form of HaNDL, or, alternatively, as a migraine-like syndrome triggered by meningeal irritation.