• José Barros, Joana Damásio, Assunção Tuna, Ivânia Alves, Isabel Silveira, José Pereira-Monteiro, Jorge Sequeiros, Isabel Alonso, Alda Sousa, and Paula Coutinho.
• Serviço de Neurologia, Hospital de Santo António, Centro Hospitalar do Porto, Porto, Portugal. josebarros.neuro@hgsa.min-saude.pt
• JAMA Neurol. 2013 Feb 1;70(2):235-40.

ObjectiveTo document and discuss the broad phenotypic variability in a Portuguese family with cerebellar ataxia, hemiplegic migraine, and related syndromes caused by missense mutation c.1748 (p.R583Q) in the CACNA1A gene.DesignObservational 12-year follow-up study.SettingCommunity and hospital care.PatientsSixteen patients in a 4-generation family were identified in 1998 in a population-based survey. The follow-up revealed 28 patients (25 of whom were observed) and 32 unaffected relatives with an a priori risk of 50%.ResultsFour major phenotypes (migraine with multiple auras, transient focal neurological deficits without headache, coma triggered by minor head trauma, and slowly progressive cerebellar ataxia) were present in various combinations. The initial manifestation was ataxia in 16 patients and a transient episode in 12 patients. Eighteen patients did not have migraine, and 11 showed only ataxia. The c.1748 (p.R583Q) mutation in CACNA1A was confirmed in all 23 of the patients who were tested but was not found in any of the 27 adult relatives. The CACNA1A CAG repeat expansion was excluded.ConclusionsA unique missense mutation in the CACNA1A gene, which exhibits a very high penetrance and expressivity, may present a phenotypic spectrum that is broader than current descriptions. Single-gene disorders can behave as complex traits, which reinforces the importance of genetic modifiers in the tightly regulated function of P/Q-type calcium channels. The clinical spectrum of missense mutation CACNA1A -related disorders is much broader than strictly familial hemiplegic migraine.

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