Migraine with visual aura, unilateral mydriasis and Takotsubo Syndrome. Random coincidence or common pathogenesis? The precarious balance of the autonomic nervous system and the complex relationship between brain and heart: a review of the literature.

OBJECTIVE: The recent examination of a woman who presented a migraine attack with visual aura and unilateral mydriasis, followed, a few days later, by an episode of Takotsubo Syndrome, prompted us to review the existing literature correlating migraine and TS as well as the most recent studies regarding the association between Takotsubo Syndrome and neurological dysfunction. Our aim is to define the role of dysautonomia and the contribution of the Autonomic Nervous System in the pathogenesis of both diseases, also, to define the functional role of the hypothalamus in the both the determination of headache attacks and the onset of clinical manifestations in other organs and tissues.

BACKGROUND: Migraine with aura and Takotsubo Syndrome (TS) share emotional, psychological and physical triggering factors which are implicated in the pathogenetic process. The autonomic nervous system plays a crucial, though antipodal, role in both pathologies. Indeed, migraine clinical manifestations imply the activation of the parasympathetic system whereas a massive catecholamine release following sympathetic nervous system activation is pivotal in triggering the Takotsubo Syndrome.

METHODS: Review of anatomy, physiology and neural regulation in both physiological and stress responses. Examination of the functional connections of the hypothalamus.

RESULTS AND DISCUSSION: The coexistence of psycho-emotional stressors, endocrine/hormonal factors and a possible genetic predisposition might explain the pathophysiological overlap between these two distinct clinical manifestations. The hypothalamus is functionally connected with all the pain-related brain regions and pathways and can be responsible for the clinical manifestations in both the nervous system and the cardiovascular apparatus. Migraine is the most frequent chronic, early onset condition associated with TS.