[David in Seattle]

Mov Disord. 2009;24:2358-2362.

January 7, 2010 — Migraine and carpal tunnel syndrome are common among celiac patients, a new study shows.

After screening a cohort of 72 patients with biopsy-proven celiac disease, researchers also report that many experience psychiatric problems, with 35% of celiac patients reporting a history of depression, personality changes, or psychosis.

Atypical neurological presentations are thought to occur in 6% to 10% of celiac patients, the study authors note. Prior studies have suggested that cerebellar ataxia is the most frequent symptom. This new study observed cerebellar ataxia in 6% of patients. Another 6% had vestibular dysfunction. In all, 26% of patients experienced afferent ataxia.

About a third of patients had stance and gait problems, and many experienced deep sensory loss and reduced ankle reflexes.

"Gait disturbances in celiac disease do not only result from cerebellar ataxia but also from proprioceptive or vestibular impairment," report investigators led by Katrin Bürk, MD, from the University of Marburg in Germany. "Neurological problems may develop despite strict adherence to a gluten-free diet."

Neurological problems may develop despite strict adherence to a gluten-free diet.

The study is published in the December 15 issue of Movement Disorders.

The 72 patients with celiac disease were recruited through advertisements and interviewed using a standard questionnaire.

"Most studies in this field are focused on patients under primary neurological care," the researchers note. "To exclude such an observation bias, patients with biopsy-proven celiac disease were screened for neurological disease."

About a third of celiac patients (28%) reported a history of migraine. In many cases, there was a decrease in the frequency and intensity of migraine attacks after the introduction of a gluten-free diet.

About 20% of patients experienced carpal tunnel syndrome. "Surprisingly, epilepsy was less common than expected," report the researchers. "Only 4 individuals presented with a history of generalized or focal seizures."

Motor problems, such as basal ganglia symptoms, pyramidal tract signs, tics, and myoclonus, were infrequent. A total of 14% of patients reported bladder dysfunction.

Multiple Mechanisms Likely

In celiac disease, the mechanisms leading to neurological disease are not yet understood. Deficiencies in folic acid, vitamin E, and biopterin have been implicated in the pathogenesis; however, the investigators report that replacement therapy does not resolve clinical symptoms in most cases.

The researchers point out that hypovitaminosis rarely causes overt abnormalities in celiac patients, and most with neurological symptoms do not show evidence of any nutritional deficiencies.

"The prevalence of neurological manifestations in celiac disease is striking and must be considered more than accidental," they note. "The patients' gluten-free diet had resolved intestinal symptoms but had not prevented the development of neurological deficits."

The investigators suggest that because of the considerable clinical variability, many different pathogenic mechanisms are likely to contribute to the neurological and psychiatric dysfunction in celiac disease.