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Familial Hemiplegic Migraine

Includes: Familial Hemiplegic Migraine 1, Familial Hemiplegic Migraine 2, Familial Hemiplegic Migraine 3
, MD, PhD
Department of Neurology
UCLA School of Medicine
Los Angeles, California

Initial Posting: ; Last Update: September 8, 2009.

Summary

Disease characteristics. Familial hemiplegic migraine (FHM) falls within the category of migraine with aura. In migraine with aura (including familial hemiplegic migraine) the neurologic symptoms of aura are unequivocally localizable to the cerebral cortex or brain stem and include visual disturbance (most common), sensory loss (e.g., numbness or paresthesias of the face or an extremity), and dysphasia (difficulty with speech); FHM must include motor involvement, i.e., hemiparesis (weakness of an extremity). Hemiparesis occurs with at least one other symptom during FHM aura. Neurologic deficits with FHM attacks can be prolonged for hours to days and may outlast the associated migrainous headache. FHM is often earlier in onset than typical migraine, frequently beginning in the first or second decade; the frequency of attacks tends to decrease with age. Approximately 40%-50% of families with FHM1 have cerebellar signs ranging from nystagmus to progressive, usually late-onset mild ataxia. Cerebral infarction and death have rarely been associated with hemiplegic migraine.

Diagnosis/testing. Diagnostic criteria for FHM: (1) fulfills criteria for migraine with aura; (2) aura includes some degree of hemiparesis and may be prolonged; (3) at least one first-degree relative (i.e., parent, sib, offspring) has identical attacks. Three genes are known to be associated with FHM: CACNA1A (FHM1), ATP1A2 (FHM2), and SCN1A (FHM3).

Management. Treatment of manifestations: A trial of acetazolamide for individuals with FHM1 or a trial of standard migraine prophylactic drugs (tricyclic antidepressants, beta blockers, calcium channel blockers) for all FHM types may be warranted for frequent attacks.

Agents/circumstances to avoid: Vasoconstricting agents because of the risk of stroke; cerebral angiography as it may precipitate a severe attack.

Genetic counseling. Because the diagnosis of FHM requires at least one affected first-degree relative, most individuals diagnosed with familial hemiplegic migraine have an affected parent. The proportion of cases caused by de novo gene mutations is unknown. Each child of an individual with familial hemiplegic migraine has a 50% chance of inheriting the mutation. Prenatal testing for pregnancies at increased risk is possible if the disease-causing mutation in the family has been identified.

Diagnosis

Clinical Diagnosis

The diagnosis of familial hemiplegic migraine (FHM) relies on clinical diagnostic criteria. Two sets of criteria have been proposed:

Criteria adapted from the Headache Classification Subcommittee of the International Headache Society [2004]

Familial hemiplegic migraine (FHM) is a category of migraine with aura (MA). Diagnostic criteria for FHM are as follows:

  • Headaches fulfill criteria for MA*.
  • Aura includes some degree of hemiparesis and may be prolonged.
  • At least one first-degree relative (i.e., parent, sib, and/or offspring) has identical attacks.

*Migraine with aura (MA) is an idiopathic, recurring disorder of neurologic symptoms unequivocally localizable to the cerebral cortex or brain stem. The aura usually develops over a period of five to 20 minutes and lasts less than 60 minutes. Headache, nausea and/or photophobia usually follow neurologic aura symptoms, either immediately or after a symptom-free interval of less than an hour. The headache usually lasts four to 72 hours but may be completely absent (acephalagia). Diagnostic criteria for MA:

  • At least two episodes characterized by three or more of the following:
    • One or more aura symptoms are fully reversible, indicating focal cerebral cortical and/or brain stem dysfunction.
    • At least one aura symptom develops gradually over more than four minutes, or two or more symptoms occur in succession.
    • No aura symptom lasts more than 60 minutes. If more than one aura symptom is present, duration of symptoms is proportionally increased.
    • Headache follows aura with a symptom-free interval of less than 60 minutes (headache may also begin before or simultaneously with the aura).
  • Ruling out of other classes of headache (i.e., head trauma, vascular disorders, nonvascular intracranial disorders, substance use or their withdrawal, non-cephalic infection, metabolic disorder, pain associated with other facial or cranial disorders)

Criteria proposed by Thomsen et al [2002]*

At least two attacks that meet all of the following criteria:

  • Fully reversible symptoms including motor weakness and at least one of the following: visual, sensory, or speech disturbance
  • At least two of the following:
    • At least one aura symptom develops gradually over at least five minutes, or symptoms occur in succession.
    • Each aura symptom lasts less than 24 hours.
    • Some degree of headache is associated with the aura.
  • Not attributed to another disorder
  • At least one first- or second-degree relative with migraine with aura including motor weakness and fulfilling all of the criteria above

*Based on findings in 147 affected individuals from 44 families

Molecular Genetic Testing

Genes. Three genes are known to be associated with familial hemiplegic migraine:

  • CACNA1A. Familial hemiplegic migraine type 1 (FHM1), commonly presenting with nystagmus and other cerebellar signs [Ophoff et al 1996], was previously estimated to account for 50% of FHM. However, in a recent population-based study in Denmark, molecular genetic testing revealed that three of 42 (7%) of the 44 families tested had FHM1 [Thomsen et al 2007].
  • ATP1A2. Familial hemiplegic migraine type 2 (FHM2), frequently occurring with epilepsy [DeFusco et al 2003], appeared in the past to be less prevalent than FHM1, with far fewer case reports in the literature. In a recent population-based study in Denmark, molecular genetic testing revealed that three of 42 (7%) of the 44 families tested had FHM2 [Thomsen et al 2007].
  • SCN1A. Familial hemiplegic migraine type 3 (FHM3) [Dichgans et al 2005a] has been reported in several unrelated families in the literature.

Other loci

Clinical testing

CACNA1A

  • Sequence analysis. Direct sequencing of all known exons and flanking introns would reliably reveal point mutations or very small frameshift mutations, but the actual mutation detection frequency is unknown.

    Note: The sensitivity of screening by SSCP or dHPLC as performed in various research laboratories has been estimated to be greater than 80% but imperfect.
  • Deletion/duplication analysis. A 39.5-kb CACNA1A deletion of the last 16 coding exons was reported in three affected members of one family with episodic ataxia [Riant et al 2008]. The frequency of other partial- or whole-gene deletions is unknown.

ATP1A2

  • Sequence analysis. Direct sequencing of all known exons and flanking introns would reliably reveal point mutations or very small frameshift mutations, but the actual mutation detection frequency is unknown.

SCN1A

  • Sequence analysis/mutation scanning. Direct sequencing of all known exons and flanking introns would reliably reveal point mutations or very small frameshift mutations, but the actual mutation detection frequency is unknown.
  • Deletion/duplication analysis. To date, no report of SCN1A deletions or duplications as causative of FHM has been published.

Table 1. Summary of Molecular Genetic Testing Used in Familial Hemiplegic Migraine

Gene Symbol
(Locus Name)
% of all FHMTest MethodMutations DetectedMutation Detection Frequency by Gene and Test Method 1
CACNA1A (FHM1)7%Sequence analysisSequence variants 2Unknown
UnknownDeletion/ duplication analysis 3Exonic or whole-gene deletionsUnknown
ATP1A2 (FHM2)7%Sequence analysisSequence variants 2Unknown
SCN1A (FHM3)RareSequence analysis/ mutation scanning Sequence variants 2Unknown
Deletion/ duplication analysis 3Exonic or whole-gene deletionsUnknown

1. The ability of the test method used to detect a mutation that is present in the indicated gene

2. Examples of mutations detected by sequence analysis may include small intragenic deletions/insertions and missense, nonsense, and splice site mutations.

3. Testing that detects deletions/duplications not readily detectable by sequence analysis of genomic DNA; a variety of methods including quantitative PCR, real-time PCR, multiplex ligation-dependent probe amplification (MLPA), or array GH may be used.

Interpretation of test results. For issues to consider in interpretation of sequence analysis results, click here.

Testing Strategy

To establish the genetic basis of FHM in a proband, identification of mutation in one of the three known associated genes by molecular genetic testing is necessary.

Note: (1) In the majority of persons with adult-onset hemiplegic migraine without nystagmus, seizures, or other unusual associated neurologic features, the yield for genetic testing is low. (2) Multiple studies have shown that mutations in the three known FHM-related genes are not major causes of simplex hemiplegic migraine (i.e., hemiplegic migraine in a single person in a family).

Predictive testing for at-risk asymptomatic adult family members requires prior identification of the disease-causing mutation in the family.

Prenatal diagnosis and preimplantation genetic diagnosis (PGD) for at-risk pregnancies require prior identification of the disease-causing mutation in the family.

Clinical Description

Natural History

In migraine with aura, including familial hemiplegic migraine, the neurologic symptoms of aura are unequivocally localizable to the cerebral cortex or brain stem and include visual disturbance (most common), sensory loss (e.g., numbness or paresthesias of the face or an extremity), and dysphasia (difficulty with speech), and for FHM must include motor involvement (e.g., hemiparesis [weakness of an extremity]) [Thomsen et al 2002]:

  • Visual disturbances can include scotoma (blind spots), photopsia (flashing lights), fortification spectra (zigzag pattern), and diplopia (double vision).
  • Dysphasia usually occurs when hemiplegia is right-sided.
  • Hemiparesis occurs with at least one other symptom during FHM aura [Ducros et al 2000].

    Note: Recent family studies found that approximately 10% of family members with a CACNA1A mutation do not have hemiplegic attacks but often have migraine with or without aura [Ducros et al 2001].

Some confusion and/or drowsiness may be present even without dysphasia. Impaired consciousness ranging from drowsiness to coma is well described in FHM [Terwindt et al 1998, Chabriat et al 2000, Vahedi et al 2000]. Intermittent confusion and psychosis have been reported [Feely et al 1982] including one probable family with FHM1 and ataxia [Spranger et al 1999].

Neurologic deficits with FHM attacks can be prolonged for hours to days and may outlast the associated migrainous headache. Persistent attention and memory loss can last weeks to months [Kors 2003]. Permanent motor, sensory, language, or visual symptoms are extremely rare [Ducros et al 2001].

Cerebral infarction and death have rarely been associated with hemiplegic migraine and should instead raise the possibility of other disorders associated with migraine and stroke (see Differential Diagnosis).

Familial hemiplegic migraine is often earlier in onset than typical migraine, frequently beginning in the first or second decade. In the report of Ducros et al [2001], the attacks started at a young age in the majority of subjects (mean: 11.7 ±8 years; range: 1-51 years). The natural history was variable. The frequency of attacks ranged from one per day to fewer than five in a lifetime (mean: 2-3/year). Long attack-free intervals were often reported (range: 2-37 years). The frequency of FHM attacks tends to decrease with age. The eventual neurologic outcome is often benign in the pure FHM group, although FHM1 can have progressive cerebellar deficit.

FHM attacks may be provoked by typical migraine triggers (e.g., foods, odors, exertion, stress), minor head trauma, and cerebral angiography.

Among families with hemiplegic migraine, the major significant clinical differences are presence or absence of cerebellar signs ranging from nystagmus to progressive, usually late-onset mild ataxia, which occurs in up to 40%-50% of families with FHM1 [Ducros et al 2000]; within such families, up to 60% of affected individuals have permanent cerebellar signs [Ducros et al 2001].

Seizures during severe attacks have been reported in some families with FHM2 along with recurrent coma in one individual [Echenne et al 1999]. Focal seizures during severe attacks have been described in two individuals with FHM1 who have no family history of FHM1 [Chabriat et al 2000], including one with severe intellectual disability, congenital ataxia, and early cerebellar atrophy [Vahedi et al 2000].

Imaging studies. The only abnormalities observed on traditional imaging studies are vermian cerebellar atrophy in some families with FHM1 [Battistini et al 1999]. Rare exceptions include transient diffusion-weighted signal changes on head MRI suggesting cytotoxic edema during severe prolonged attacks in individuals with FHM1 [Chabriat et al 2000, Vahedi et al 2000] with hemispheric cerebral atrophy usually contralateral to the hemiparesis [Hayashi et al 1998, Chabriat et al 2000, Vahedi et al 2000].

Abnormalities in the cerebellum on magnetic resonance spectroscopy (MRS) have been reported [Dichgans et al 2005b].

Genotype-Phenotype Correlations

CACNA1A. Although further correlation is needed, some suggestive genotype-phenotype correlations exist based on limited data regarding CACNA1A mutations commonly presenting with nystagmus and other cerebellar signs [Ophoff et al 1996]:

  • p.Arg192Gln and p.Val1457Leu [Carrera et al 1999] are associated with hemiplegic attacks only, whereas unconsciousness occurs commonly during attacks with mutation p.Val714Ala [Terwindt et al 1998].
  • p.Thr666Met, p.Ile1811Leu, p.Arg583Gln [Alonso et al 2003], and p.Asp715Glu [Ducros et al 1999] have been associated with hemiplegic attacks plus ataxia. In the Ducros et al [2001] study, p.Thr666Met was associated with the highest frequency of hemiplegic migraine, severe attacks of coma, and nystagmus. During attacks, unconsciousness sometimes occurs in individuals with the p.Thr666Met and p.Ile1811Leu mutations [Terwindt et al 1998]. Kors et al [2003] reported a family with the p.Thr666Met mutation and progressive cognitive dysfunction.
  • p.Arg583Gln can be associated with stupor, fever, and progressive ataxia [Battistini et al 1999, Ducros et al 2001]. Affected individuals were thought to have fewer attacks after treatment with acetazolamide.
  • p.Asp715Glu has the lowest frequency (64%) of attacks of hemiplegic migraine [Ducros et al 2001].
  • A de novo mutation p.Tyr1385Cys identified in a single individual with no known family history of FHM has been associated with prolonged severe attacks including focal seizures, coma, fever, and CSF neutrophilic pleocytosis [Chabriat et al 2000, Vahedi et al 2000]. Cerebral hemispheric and cerebellar atrophy are seen on imaging studies [Vahedi et al 2000] with reversible MRI signal changes suggestive of cytotoxic edema during attacks [Chabriat et al 2000]. Additionally, the single individual with mutation p.Thr1384Cys had otherwise unexplained severe intellectual disability, developmental delay, and congenital or early-onset ataxia.
  • p.Ser218Leu has been associated with delayed cerebral edema and fatal coma after minor head trauma [Kors et al 2001].

See Table 2.

ATP1A2

  • In the first two families in which FHM2 was genetically defined, De Fusco et al [2003] noted the history of seizures in several affected individuals. Subsequent reports of FHM2 further suggest seizures as an associated clinical feature.
  • A severe phenotype with seizures, coma, and elevated temperature has been reported with a p.Gly301Arg mutation in ATP1A2 [Spadaro et al 2004].
  • A severe phenotype with seizures and intellectual disability has been reported with the mutations p.Asp718Asn and p.Pro979Leu [Jurkat-Rott et al 2004].

See Table 3.

Penetrance

Penetrance is estimated to be approximately 80% [Jurkat-Rott et al 2004, Riant et al 2005].

Nomenclature

Although families with FHM in which attacks are strikingly identical do exist, the term familial hemiplegic migraine is often used inconsistently to describe families in which different forms of migraine occur, as most individuals with hemiplegic attacks have these attacks intermingled with more frequent attacks of migraine without hemiparesis.

Prevalence

In Denmark, Thomsen et al [2002] found the prevalence of hemiplegic migraine to be 0.01% with a M:F sex ratio of 1:3 and equal prevalence of familial and sporadic cases.

Differential Diagnosis

Migraine without aura. Migraine without aura (MO or MOA) (common migraine) is an idiopathic, recurring headache disorder manifesting in attacks lasting four to 72 hours. Typical characteristics of the headache are unilateral location, pulsating quality, moderate or severe intensity, aggravation by routine physical activity, and association with nausea, photophobia, and phonophobia. This headache occurs without neurologic aura symptoms and specifically without hemiparesis.

Typical migraine is thought to be genetically complex and to have undefined environmental components. A clinical distinction between familial and nonfamilial cases has long been entertained, beginning with the first report of FHM by JM Clark [1910]. Wieser et al [2003] found no mutations in CACNA1A in individuals with common migraine. Some families having migraine without aura have shown linkage to 4q21 [Bjornsson et al 2003] and 14q21.2-q22.3 [Soragna et al 2003]. One family having migraine with or without aura showed linkage to 6p12.2-p21.1 [Carlsson et al 2002].

Migraine with aura. Brugnoni et al [2002] found no CACNA1A mutations in individuals with familial migraine with aura. Some families having migraine with aura show linkage to 4q24 [Wessman et al 2002].

"Sporadic" hemiplegic migraine (SHM). "Sporadic" hemiplegic migraine refers to simplex cases (i.e., affected individuals with no relatives with hemiplegic migraine). Such individuals may or may not have other family members with typical migraine. To investigate the genetic basis of hemiplegic migraine in simplex cases:

  • Terwindt et al [2003] evaluated 27 individuals who had no family history of hemiplegic migraine and found a mutation in CACNA1A in two, one of whom had ataxia, nystagmus, and cerebellar atrophy on cranial CT; the other did not.
  • de Vries et al [2007] sequenced all three FHM-related genes in 39 individuals with SHM and found one CACNA1A mutation (FHM1), five ATP1A2 mutations (FHM2), and one SCN1A polymorphism (FHM3).
  • Thomsen et al [2008] examined 100 individuals with SHM and found only a handful of novel, not clearly pathogenic nucleotide variants in CACNA1A and ATP1A2, suggesting that FHM-related genes are not major genes in SHM.

Other inherited disorders associated with migrainous headache that may include hemiplegic aura:

  • MELAS, MERRF, and other mitochondrial disorders. MELAS is a multisystem disorder with onset typically between ages two and ten years. The most common initial symptoms are generalized tonic-clonic seizures, recurrent headaches, anorexia, and recurrent vomiting. Seizures are often associated with stroke-like episodes of transient hemiparesis or cortical blindness, which may be associated with altered consciousness and may be recurrent. The cumulative residual effects of the stroke-like episodes gradually impair motor abilities, vision, and cognition, often by adolescence or young adulthood. Sensorineural hearing loss is common. The most common mitochondrial DNA (mtDNA) mutation, present in more than 80% of individuals with typical clinical findings of MELAS, is an A-to-G transition at nucleotide 3243 in the tRNALeu(UUR) of mtDNA.
  • CADASIL (cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy) is characterized by history of migraine headaches, mid-adult (30s-60s) onset of cerebrovascular disease progressing to dementia, and diffuse white matter deficits on neuroimaging. One family with CADASIL was reported to have hemiparetic aura [Hutchinson et al 1995]. The pathologic hallmark of CADASIL is electron-dense granules in the media of arterioles that can often be identified by electron microscopic (EM) evaluation of skin biopsies. More than 90% of individuals have mutations in NOTCH3. Inheritance is autosomal dominant.
  • RVCL (retinal vasculopathy with cerebral leukodystrophy) is characterized by systemic microvasculopathy with adult onset (30s-40s) of retinal vasculopathy and cerebrovascular disease variably associated with migraine. The pathologic hallmark of RVCL is multi-laminated subendothelial basement membrane by EM evaluation of multiple organs including skin. Affected individuals have mutations in TREX1. Inheritance is autosomal dominant.
  • Hereditary hemorrhagic telangiectasia (HHT) results from the presence of multiple arteriovenous malformations (AVMs) that lack intervening capillaries and result in direct connections between arteries and veins. Small AVMs, or telangiectases, close to the surface of skin and mucous membranes often rupture and bleed after slight trauma. The most common clinical manifestation is spontaneous and recurrent nosebleeds beginning at approximately age 12 years. Large AVMs often cause symptoms when they occur in brain, lung, or the gastrointestinal tract; complications from bleeding or shunting may be sudden and catastrophic. Migraine with aura has been reported in 50% of affected individuals. HHT is caused by a mutation either in ENG or ACVRL1. Inheritance is autosomal dominant.
  • Essential tremor (ET). Familial progressive kinetic and postural tremor usually involves the upper extremities and head and sometimes the voice. Autosomal dominant inheritance may be present in some families and has been associated with migraine in one study [Baloh et al 1996].
    • Familial essential tremor type 1 (FET1) has been mapped to 3q13.
    • FET2 was mapped to2p22-p25.
    • A genome-wide association study on a large cohort with ET identified a marker in LINGO1 that confers significant risk for ET [Stefansson et al 2009].

      Note: A proposed association of ET with a polymorphism in DRD3 located on 3q13 has not been confirmed.
  • Familial cerebral cavernous malformations (CCMs) are vascular malformations consisting of closely clustered enlarged capillary channels (caverns) with a single layer of endothelium without normal intervening brain parenchyma or mature vessel wall elements. CCMs have been reported in infants and children, but the majority of individuals present with symptoms between the second and fifth decades. Approximately 50%-75% of persons with CCM have symptoms, including seizures, focal neurologic deficits, nonspecific headaches, and cerebral hemorrhage. Up to 25% of individuals with CCM remain symptom free throughout their lives. The three genes associated with familial CCM are KRIT1, CCM2, and CCM3. A single mutation in KRIT1, p.Gln455* (c.1363C>T) (reference sequence NM_194455.1), has been identified in approximately 70% of affected Hispanic families. Inheritance is autosomal dominant.
  • Dutch form of hereditary cerebral amyloid angiopathy. Migraines often precede the onset of cerebral and cerebellar hemorrhage in the fourth or fifth decade. Senile plaques and vascular wall amyloid are found in the brain in association with amino acid changes in the APP beta-amyloid precursor protein, a protease inhibitor. Inheritance is autosomal dominant.

Hemiplegia. The differential diagnosis of hemiplegia includes post-ictal weakness following seizure, transient ischemic attack (TIA), stroke, and other non-genetic causes of transient hemiparesis.

Stroke. When family history is positive for hemiparetic attacks with migraine, the presence of infarct on imaging studies raises the possibility of other inherited disorders such as MELAS, CADASIL, or thrombophilia, such as factor V Leiden [Gaustadnes et al 1999]. Additional stroke risk factors may also be present.

Caution: Even with normal imaging studies and description of spreading aura, an age-appropriate stroke evaluation should be considered at presentation. Overlap in clinical features, inaccuracies of historical family information, rarity of true FHM, and the seriousness of stroke-related disorders warrant this cautious approach. Stroke or other CNS-related disorders should be even more strongly considered if family history is negative for hemiplegic migraine.

Management

Evaluations Following Initial Diagnosis

To establish the extent of disease in an individual diagnosed with familial hemiplegic migraine (FMH), the following evaluations are recommended:

  • Quantitative eye movement examination in individuals with nystagmus or complaints of incoordination or imbalance to look for additional clues of cerebellar involvement
  • EEG and neuroimaging studies if seizures are present in order to further characterize the seizure disorder.

Treatment of Manifestations

A trial of acetazolamide for individuals with FHM1 or a trial of standard migraine prophylactic drugs (tricyclic antidepressants, beta blockers, calcium channel blockers) for all FHM types may be warranted for frequent attacks. Limited correlation exists between drug response and hemiplegic migraine type.

Agents/Circumstances to Avoid

In general, vasoconstricting agents should be avoided because of the risk of stroke.

Cerebral angiography is hazardous as it may precipitate a severe attack [Chabriat et al 2000].

Evaluation of Relatives at Risk

See Genetic Counseling for issues related to testing of at-risk relatives for genetic counseling purposes.

Therapies Under Investigation

Search ClinicalTrials.gov for access to information on clinical studies for a wide range of diseases and conditions. Note: There may not be clinical trials for this disorder.

Genetic Counseling

Genetic counseling is the process of providing individuals and families with information on the nature, inheritance, and implications of genetic disorders to help them make informed medical and personal decisions. The following section deals with genetic risk assessment and the use of family history and genetic testing to clarify genetic status for family members. This section is not meant to address all personal, cultural, or ethical issues that individuals may face or to substitute for consultation with a genetics professional. —ED.

Mode of Inheritance

Familial hemiplegic migraine is inherited in an autosomal dominant manner.

Risk to Family Members

Parents of a proband

Sibs of a proband

  • The risk to the sibs of a proband depends on the genetic status of the parents.
  • If a parent of the proband is affected, the risk to the sibs is 50%.
  • When the parents are clinically unaffected, the risk to the sibs of a proband appears to be low.
  • If the disease-causing mutation in the proband cannot be detected in the DNA of either parent, two possible explanations are germline mosaicism in a parent or a de novo mutation in the proband. Although no instances of germline mosaicism have been reported, it remains a possibility.

Offspring of a proband. Each child of an individual with familial hemiplegic migraine has a 50% chance of inheriting the mutation.

Other family members of a proband. The risk to other family members depends on the genetic status of the proband's parents. If a parent is affected, his or her family members are at risk.

Related Genetic Counseling Issues

Considerations in families with an apparent de novo mutation. When neither parent of a proband with an autosomal dominant condition has clinical evidence of the disorder, it is likely that the proband has a de novo mutation. However, possible non-medical explanations including alternate paternity or maternity (e.g., with assisted reproduction) or undisclosed adoption could also be explored.

Family planning

  • The optimal time for determination of genetic risk is before pregnancy.
  • It is appropriate to offer genetic counseling (including discussion of potential risks to offspring and reproductive options) to young adults who are affected or at risk of being affected.

DNA banking is the storage of DNA (typically extracted from white blood cells) for possible future use. Because it is likely that testing methodology and our understanding of genes, mutations, and diseases will improve in the future, consideration should be given to banking DNA of affected individuals.

Prenatal Testing

Prenatal diagnosis for pregnancies at increased risk for FHM is possible by analysis of DNA extracted from fetal cells obtained by amniocentesis usually performed at approximately 15 to 18 weeks’ gestation or chorionic villus sampling (CVS) at approximately ten to 12 weeks’ gestation. The disease-causing allele of an affected family member must be identified before prenatal testing can be performed.

Note: Gestational age is expressed as menstrual weeks calculated either from the first day of the last normal menstrual period or by ultrasound measurements.

Requests for prenatal testing for conditions which (like FHM) do not affect intellect or life span are not common. Differences in perspective may exist among medical professionals and within families regarding the use of prenatal testing, particularly if the testing is being considered for the purpose of pregnancy termination rather than early diagnosis. Although most centers would consider decisions about prenatal testing to be the choice of the parents, discussion of these issues is appropriate.

Preimplantation genetic diagnosis (PGD) may be an option for some families in which the disease-causing mutation has been identified.

Resources

GeneReviews staff has selected the following disease-specific and/or umbrella support organizations and/or registries for the benefit of individuals with this disorder and their families. GeneReviews is not responsible for the information provided by other organizations. For information on selection criteria, click here.

  • National Library of Medicine Genetics Home Reference
  • MAGNUM - Migraine Awareness Group: A National Understanding for Migraineurs
    The National Migraine Association
    100 North Union Street
    Suite B
    Alexandria VA 22314
    Phone: 703-349-1929
    Fax: 800-884-1300 (toll-free)
    Email: comments@migraines.org
  • National Headache Foundation
    820 North Orleans
    Suite 411
    Chicago IL 60610
    Phone: 888-NHF-5552
    Email: info@headaches.org

Molecular Genetics

Information in the Molecular Genetics and OMIM tables may differ from that elsewhere in the GeneReview: tables may contain more recent information. —ED.

Table A. Familial Hemiplegic Migraine: Genes and Databases

Data are compiled from the following standard references: gene symbol from HGNC; chromosomal locus, locus name, critical region, complementation group from OMIM; protein name from UniProt. For a description of databases (Locus Specific, HGMD) to which links are provided, click here.

Table B. OMIM Entries for Familial Hemiplegic Migraine (View All in OMIM)

141500MIGRAINE, FAMILIAL HEMIPLEGIC, 1; FHM1
182340ATPase, Na+/K+ TRANSPORTING, ALPHA-2 POLYPEPTIDE; ATP1A2
182389SODIUM CHANNEL, NEURONAL TYPE I, ALPHA SUBUNIT; SCN1A
601011CALCIUM CHANNEL, VOLTAGE-DEPENDENT, P/Q TYPE, ALPHA-1A SUBUNIT; CACNA1A
602481MIGRAINE, FAMILIAL HEMIPLEGIC, 2; FHM2
609634MIGRAINE, FAMILIAL HEMIPLEGIC, 3; FHM3

CACNA1A

Normal allelic variants. 47 exons; 300 kb

Pathologic allelic variants. The mutation p.Thr666Met is the most common, with no evidence for founder effect [Ducros et al 1999]. See Table 2.

Table 2. Selected CACNA1A Pathologic Allelic Variants

DNA Nucleotide Change
(Alias 1)
Protein Amino Acid Change
(Alias 1)
Reference Sequences
c.575G>Ap.Arg192GlnNM_001127221​.1
NP_001120693​.1
X99897 2
c.653C>Tp.Ser218Leu
c.1748G>Ap.Arg583Gln
c.2141T>Cp.Val714Ala
c.2145C>Gp.Asp715Glu
c.1997C>Tp.Thr666Met
c.4151A>G
(c.4154A>G) 2
p.Tyr1384Cys
(p.Tyr1385Cys) 2
c.5428A>C
(c.5431A>C) 2
p.Ile1810Leu
(p.Ile1811Leu) 2
c.4366G>T
(c.4369G>T) 2
p.Val1456Leu
(p.Val1457Leu) 2

Note on variant classification: Variants listed in the table have been provided by the author(s). GeneReviews staff have not independently verified the classification of variants.

Note on nomenclature: GeneReviews follows the standard naming conventions of the Human Genome Variation Society (www​.hgvs.org). See Quick Reference for an explanation of nomenclature.

1. Variant designation that does not conform to current naming conventions

2. Variant designations are given for an alternate reference sequence. X99897 is an alternate cDNA commonly used in the literature. Compared to NM_001127221.1, it has an extra three nucleotides (AAG) at nucleotide 3623_3625, resulting in an additional Glu residue.

Normal gene product. The gene encodes the alpha-1 subunit of a neural voltage-dependent P/Q-type calcium channel. The alpha-1 subunit forms the pore of the calcium channel.

Abnormal gene product. Mutations affect the pore or the voltage sensor parts of the ion channel. Tottene et al [2002] found that mutational changes of functional channel densities can be different in different cell types, and identified two functional effects common to all FHM-causing mutations analyzed: increase of single-channnel Ca2+ influx and decrease of maximal Ca(V)2.1 current density in neurons.

ATP1A2

Normal allelic variants. Numerous intronic and exonic normal allelic variants have been identified.

Pathologic allelic variants. Since the first report of p.Leu764Pro, p.Trp887Arg [De Fusco et al 2003], more than 40 mutations in ATP1A2 have been described in FHM2 or sporadic hemiplegic migraine. The great majority are missense mutations, with a handful of frameshift mutations [Riant et al 2005]. A de novo nonsense mutation p.Tyr1009* was recently identified in a child with sporadic hemiplegic migraine and epilepsy [Gallanti et al 2008]. A point mutation p.*1021Arg (*1021R) altered the termination code to add 28 novel amino acid residues to the C terminus [Jurkat-Rott et al 2004]. See Table 3.

Table 3. Selected ATP1A2 Pathologic Allelic Variants

DNA Nucleotide Change Protein Amino Acid Change
(Alias 1)
Reference Sequences
c.901G>Ap.Gly301ArgNM_000702​.3
NP_000693​.1
c.2066G>Ap.Arg689Gln
c.2152G>Ap.Asp718Asn
c.2192T>Cp.Met731Thr
c.2291T>Cp.Leu764Pro
c.2659T>Cp.Trp887Arg
c.2936C>Tp.Pro979Leu
3061T>Cp.*1021Argext28
(X1021Arg)

Note on variant classification: Variants listed in the table have been provided by the author(s). GeneReviews staff have not independently verified the classification of variants.

Note on nomenclature: GeneReviews follows the standard naming conventions of the Human Genome Variation Society (www​.hgvs.org). See Quick Reference for an explanation of nomenclature.

1. Variant designation that does not conform to current naming conventions

Normal gene product. A heterodimeric protein with ten transmembrane domains with a large catalytic α-subunit and a smaller ancillary β-subunit. The pump exchanges intracellular Na+ for extracellular K+.

Abnormal gene product. The two mutations found by De Fusco et al [2003] cause loss of function of the α2-subunit leading to haploinsufficiency, which appears to be the general rule for FHM2-causing mutations. Expression studies of mostly missense mutations and p.*1021Argext28 revealed important functional domains for protein conformation, plasma membrane targeting, turnover, cation affinity, and voltage dependence [Tavraz et al 2008]. The p.*1021Argext28 mutation changes the stop codon (*) to Arg and extends the protein by a total of 28 amino acids.

SCN1A

Normal allelic variants. SCN1A comprises 26 exons spanning a transcript of 8100 nucleotides.

Pathologic allelic variants include p.Leu263Val [Castro et al 2009], p.Thr1174Ser [Gargus & Tournay 2007], p.Gln1489Lys [Dichgans et al 2005a], p.Leu1649Gln [Vanmolkot et al 2007], as well as p.Phe1499Leu and p.Gln1489His [Vahedi et al 2009]. See Table 4.

Table 4. Selected SCN1A Pathologic Allelic Variants

DNA Nucleotide Change Protein Amino Acid Change Reference Sequence
c.787C>Gp.Leu263ValAB093548​.1
c.3521C>Gp.Thr1174Ser
c.4465C>Ap.Gln1489Lys
c.4467G>Cp.Gln1489His
c.4495T>Cp.Phe1499Leu
c.4946T>Ap.Leu1649Gln

Note on variant classification: Variants listed in the table have been provided by the author(s). GeneReviews staff have not independently verified the classification of variants.

Note on nomenclature: GeneReviews follows the standard naming conventions of the Human Genome Variation Society (www​.hgvs.org). See Quick Reference for an explanation of nomenclature.

Normal gene product. The gene encodes the voltage-sensing and ion-conducting α1-subunit of a neural voltage-dependent sodium channel.

Abnormal gene product. The mutations p.Gln1489Lys and p.Leu1649Gln associated with pure hemiplegic migraine showed loss of channel function, while p.Leu263Val associated with both hemiplegic migraine and epilepsy exhibited gain of channel function [Kahlig et al 2008].

References

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Chapter Notes

Author History

Kathy Lou Gardner, MD; University of Pittsburgh (2001-2009)
Joanna C Jen, MD, PhD (2009-present)

Revision History

  • 8 September 2009 (me) Comprehensive update posted live
  • 4 January 2007 (cd) Revision: mutations in SCN1A associated with familial hemiplegic migraine type 3
  • 14 December 2004 (cd) Revision: sequence analysis of CACNA1A clinically available
  • 15 March 2004 (me) Comprehensive update posted to live Web site
  • 30 December 2003 (cd) Revision: change in test availability
  • 3 October 2002 (kg) Author revisions
  • 16 September 2002 (kg) Author revisions
  • 17 July 2001 (me) Review posted to live Web site
  • October 2000 (kg) Original submission
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