Migraine-associated hypotension and autonomic ganglionitis

To the Editor: Lee et al.1 discuss a migraine patient with fatal ictal hypotension. In the absence of autonomic ganglion neuronal or nerve fiber degeneration as well as evidence of autonomic dysfunction during a migraine attack without hypotension, it is unlikely that the infiltrative nondestructive ganglionitis was functionally significant. The case for pure autonomic (ganglionitic) dysfunction is not augmented by the following: 1) occurrence of episodic, rather than persistent, hypotension; 2) despite β-blockade, heart rate was responsive to posture during 1992; 3) postural hypotension was never recorded; 4) preterminally, heart rate was unresponsive to complete pharmacologic autonomic blockade as well as pacemaker stimulation. A completely unresponsive heart …