[Migraine with aura as early symptom of neurosyphilis]

On the basis of a case report the often difficult classification of migraine with aura and exclusion of symptomatic origin is discussed. In spring 1996 a 34-years old patient started to suffer from attacks of a migraine like headache with focal aura several times a week. While clinical examination was inconspicuous the electroencephalogram showed a general slowing of background activity with intermittent rhythmic delta-activity. NMR was normal. During treatment with flunarizine intensity and frequency of the attacks decreased, but within half a year he developed an increasing psychomotor slowing and cognitive deficit. Now cerebrospinal fluid showed a pleocytosis and highly positive treponema pallidum specific antibody index making the diagnosis of neurosyphilis reliable. Parenteral penicillin caused a delayed normalisation of mental abilities and CSF.

Headache, especially with the characteristics of migraine, is one of the most frequent symptoms of neurosyphilis and--if untreated--may be followed by transient ischemic attacks or strokes even month later. To detect this kind of symptomatic headache a careful neurological follow-up examination and early CSF-analysis are essentially necessary, because pathological electroencephalograms are not rare in migraine with aura and NMR cannot exclude an inflammatory process.