PO-30 | A chronic migraine phenotype unveiling acromegaly: diagnostic pitfalls and the impact of timely treatment

Cinzia Rita Tamborino, Gianni Difonzo, Adriana Fallacara, Damiano Paolicelli, Maria Pia Prudenzano | Headache Center, “L. Amaducci” Neurological Clinic, Policlinico General Hospital, Bari, Italy

Background: Headache is a common symptom in acromegaly, but its pathophysiology is complex and often overlooked, leading to diagnostic delays. This can reduce the effectiveness of therapies, which currently have a response rate around 50%. Acromegaly induces systemic inflammation and endothelial dysfunction through elevated GH and IGF-1 levels, contributing to headache development. Timely hormonal therapy might prevent or reduce headache severity. When headache persists, specific preventive treatments should be considered.

Methods: A 54-year-old female smoker presented with migraine worsening after menopause and becoming chronic daily in recent months despite well-controlled arterial hypertension. The post-menopausal headache exacerbation was apparently unexplained. She had a history of menstrual migraine since age 35. Additional complaints included insomnia and snoring, with no other significant symptoms. Medical history included bilateral carpal tunnel surgery at age 16, melanoma removal in July 2024, and nodular thyroid disease under endocrinological care. A brain MRI performed to exclude secondary headache revealed a pituitary macroadenoma extending into the cavernous sinus without optic chiasm compression. Visual field testing showed nasal hemifield defects (OS > OD). Endocrinological workup revealed previous galactorrhea and elevated GH and IGF-1 levels. Lanreotide therapy was initiated.

Results: After two Lanreotide injections, migraine-like headache completely resolved, with only mild, episodic pressing pain in the left occipitotemporal regions responsive to paracetamol, which also resolved after the next dose. She underwent neurosurgery in April 2025 and currently remains under endocrinological and neurosurgical follow-up. Notably, weight gain and finger enlargement -key signs of acromegaly starting in 2019 - were not initially reported and were only uncovered during a structured follow-up interview.

Conclusion: In patients presenting with worsening or chronic migraine, especially when clinical features are atypical or unexplained, secondary causes like acromegaly should be considered. Headache in acromegaly is not solely due to the mechanical effects of the adenoma but it is strongly influenced by the biochemical effects of GH and IGF-1, which promote systemic inflammation and endothelial dysfunction. Early recognition and hormonal therapy can lead to resolution of headache symptoms. Comprehensive history-taking, including probing for subtle signs of acromegaly, and appropriate neuroimaging are essential to reduce diagnostic delays and improve patient outcomes.