Rheumatoid meningitis presenting as exacerbation of pre-existing migraine with aura: A case report highlighting the diagnostic utility of the anti-cyclic citrullinated peptide antibody index

Background

Rheumatoid meningitis (RM) is a rare inflammatory complication of rheumatoid arthritis (RA). Because headache may predominate, distinguishing RM from primary headache disorders can be challenging.

Case

A 44-year-old woman with migraine with aura developed a marked increase in headache frequency during tapering of immunosuppressive therapy for RA, in parallel with worsening arthralgia. The core features remained similar to her previous migraine attacks, including scintillating scotoma, throbbing pain, and nausea, although posterior neck discomfort was new. This change in frequency and associated symptoms prompted brain magnetic resonance imaging, which showed bilateral high-convexity sulcal hyperintensities on diffusion-weighted and fluid-attenuated inversion recovery imaging. Cerebrospinal fluid examination demonstrated pleocytosis, elevated protein, and interleukin-6, and a markedly elevated anti-cyclic citrullinated peptide antibody index, supporting a clinical diagnosis of RM. Intensified corticosteroid therapy was followed by sustained improvement without recurrence.

Conclusions

This case highlights that a marked change in attack frequency or course in a patient with an established primary headache disorder should prompt evaluation for secondary headache. RM-associated inflammatory activity may have altered susceptibility to cortical spreading depression through inflammatory mediators, thereby exacerbating the patient's typical migraine phenotype.

Early neuroimaging and cerebrospinal fluid evaluation are important for timely diagnosis.