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lung cancer presenting with orthostatic hypotension and migraine - type headaches has not been previously described in the literature .
a 62-year - old caucasian male presented with headaches , typical of his migraine , after a 30-year migraine - free period .
an examination revealed a significant postural drop in bp with reflex tachycardia and no other features of dysautonomia .
prompt pharmacological treatment in patients not responding to non - pharmacological therapy can provide relief from disabling symptoms of orthostatic hypotension . in this patient , this included symptoms consistent with migraine - type headaches .
paraneoplastic effects of tumours are remote effects that are not related to the direct invasion , obstruction or metastasis .
orthostatic hypotension ( oh ) has long been recognised as a paraneoplastic effect of bronchial carcinoma .
migraine is an episodic disorder , the crux of which is a severe headache generally associated with nausea and/or light and sound sensitivity .
the case described below is that of a man presenting with a recurrence of his typical migraine - type headaches associated with oh and squamous cell lung carcinoma .
lung cancer presenting with oh and migraine - type headaches has not been previously described in the literature .
a 62-year - old caucasian male presented for inpatient assessment of a soft tissue mass in the right superior sulcus of his lung ( see fig .
he had presented to his local medical officer some weeks previously with headaches typical of his migraine as well as with right peri - orbital throbbing , nausea and photophobia .
the character and associated nausea with light sensitivity were identical to those from the distant past .
symptoms were relieved on adopting the recumbent position . in the weeks prior to admission , he had also suffered from a loss of appetite , loss of weight , right posterior chest wall pain and postural light - headedness .
his relevant past medical history included a stable ischaemic heart disease , mechanical aortic valve replacement ( life - long anticoagulation ) , atrial fibrillation , type 2 diabetes mellitus and being an ex - smoker with a 40-pack - year history .
, atorvastatin 80 mg nocte , gliclazide 60 mg mane , nebivolol 2.5 mg nocte , sitagliptin 100 mg mane , thyroxine 125 g daily and venlafaxine 75 mg mane .
an examination revealed a significant postural drop in bp ( 60 mm hg systolic and 25 mm hg diastolic ) with an appropriate increase in heart rate ( 20 bpm ) within 2 min of standing .
ct - guided biopsy of the lung mass was undertaken , which provided a diagnosis of poorly differentiated squamous cell cancer , likely of lung origin .
staging ct and a bone scan likely revealed metastatic disease in the left 5th rib and left iliac bones .
there was no evidence of metastatic disease at other sites including the brain and adrenal glands .
the patient was commenced on regular paracetamol , oxycodone and pregabalin for his headache and chest wall pain .
this was titrated up with good relief of his chest wall pain but not the headache .
significant postural bp drops continued to occur ( drop in systolic bp between 30 and 60 mm hg ) .
non - pharmacological options including increase in salt and fluid intake , wearing of compression stockings and cessation of nebivolol did not provide relief .
endocrinology , neurology and cardiology teams were consulted ; the patient was diagnosed with likely paraneoplastic aetiology for his postural hypotension . a combination of high - dose fludrocortisone ( 800 g daily ) and midodrine ( 2.5 mg t.d.s .
) achieved objective ( systolic bp falls consistently less than 20 mm hg ) and symptomatic relief of postural hypotension and the headaches .
the patient was subsequently discharged home . at outpatient review 3 weeks later ( second cycle of chemotherapy ) the patient remained free of the migraine - type headaches or postural light - headedness .
written informed consent was obtained from the patient for publication of this case report and the accompanying images .
oh is defined as a persistent , consistent , orthostatic fall in systolic bp of 20 mm hg or diastolic pressure of 10 mm hg within 3 min of standing up .
a study examining causation of oh found that 27% of patients had primary autonomic failure , 35% had secondary autonomic failure , and 38% had hypotension without evidence of generalised autonomic degeneration .
the absence of the compensatory heart rate increase with posturally - induced hypotension is typical of autonomic failure - induced oh . the patient described in this study consistently had reflex tachycardia on standing associated with his hypotension , a feature not consistent with autonomic failure .
conditions such as diabetic autonomic neuropathy are associated with widespread effects on the autonomic nervous system even in the early stages , and a lack of reflex tachycardia on standing .
siemsen and meister   described a case of autonomic failure and oh associated with lung cancer .
park et al .   demonstrated an improvement in heart rate response to posture and resolution of oh after treatment of primary lung cancer with radiotherapy .
paraneoplastic effects of tumours are remote effects that are not related to the direct invasion obstruction , or metastasis .
small cell lung cancer is the histological type ( amongst lung cancers ) most often associated with paraneoplastic neurological disorders including oh . the oh associated with small cell lung cancer histology is that of autonomic and often pan - autonomic failure .
pelosof and gerber   describe various onconeural antibodies associated with neuronal damage in these instances .
the case described here is of a patient with non - small cell histology and oh without evidence of autonomic failure .
neal et al .   described a similar case of oh ( with reflex tachycardia ) as the isolated feature of a paraneoplastic neuropathy .
their patient , however , had small cell lung cancer and elevated levels of anti - crmp-5 antibodies , an onconeural antibody associated with small cell cancer .
the well - characterised onconeural antibodies associated with paraneoplastic neurological syndromes are not associated with non - small cell lung cancers . in the definition of paraneoplastic neurological syndromes as set out by graus et al .  
this case would fall under the category of a possible paraneoplastic syndrome ( non - classical syndrome , no defined paraneoplastic antibodies and cancer present within 2 years of diagnosis ) .
gosney et al .   postulated a role for vasodilatory peptides to explain paraneoplastic oh not accompanied by other features of autonomic dysfunction , but they could not find any correlation between the peptides studied and oh . to the authors knowledge , there are no previously published case reports that have described headaches ( of any nature , including migraine type ) induced by oh in association with or as the presenting symptom of lung cancer .
migraine is an episodic disorder , the crux of which is a severe headache generally associated with nausea and/or light and sound sensitivity .
the international headache society ( ihs ) requires a headache of a minimal duration of 4 h for a diagnosis of migraine .
what the patient described fulfilled all ihs criteria for a diagnosis of migraine without aura , with the exception of the duration criterion .
the headache described here would best fit the ihs diagnosis of probable migraine ( attacks fulfilling all but one of the criteria for a diagnosis of migraine without aura ) . given the patient description of the identical characteristics to his previously diagnosed migraine ,
syncope , orthostatic intolerance and oh have long been reported as part of the migraine syndrome .
have suggested the existence of syncopal migraine ( i.e. , migraine headache immediately preceding or following syncopal episodes ) . a significantly higher proportion of their syncopal migraine subjects reported headache with tilt table testing than the migraine - without - syncope group .
a large majority of their syncopal migraine patients responded to anti - migraine therapy ( topiramate , valproate , pregabalin ) .
these authors conclude with the suggestion that anti - migraine therapy may play a role in such patients with treatment - refractory oh , a conclusion supported by gupta , who presented a case where metoclopramide relieved recurrent oh and migraine . in this case , treatment targeted towards oh led to a resolution of the patient 's headache symptoms . with
further anti - cancer treatment , fludrocortisone and midodrine doses could be reduced and possibly ceased with careful monitoring of symptoms .
however , another explanation in that instance could be permanent neuronal damage from as yet uncharacterised onconeural antibodies associated with non - small cell lung cancer . in such an instance , anti - migraine therapy may be an option for this patient , given the adverse effect profile of long - term high - dose fludrocortisone and midodrine .
to the best of the author 's knowledge , this is the first report describing a case of lung cancer presenting with oh and migraine - type headaches .
prompt pharmacological treatment in patients not responding to non - pharmacological therapy can provide relief from disabling symptoms of oh , which , in this patient , included severe headaches .
introductionorthostatic hypotension has long been recognised as a paraneoplastic effect of lung cancer . 
 lung cancer presenting with orthostatic hypotension and migraine - type headaches has not been previously described in the literature.case reporta 62-year - old caucasian male presented with headaches , typical of his migraine , after a 30-year migraine - free period . 
 an examination revealed a significant postural drop in bp with reflex tachycardia and no other features of dysautonomia . 
 investigations showed a metastatic squamous cell lung cancer . 
 pharmacological treatment of orthostatic hypotension resolved the migraine - type headaches.discussionorthostatic hypotension is associated with lung cancer . 
 prompt pharmacological treatment in patients not responding to non - pharmacological therapy can provide relief from disabling symptoms of orthostatic hypotension . in this patient , this included symptoms consistent with migraine - type headaches .