Neuroscience · Year 2 · from Neuroscience
Case 1: Migraine with Aura
Patient Presentation
Demographics: 28-year-old female
Chief Complaint: Recurrent severe headaches with visual disturbance for 5 years
History of Present Illness: The patient describes episodic headaches occurring 3-4 times per month since age 23. A typical attack begins with a visual disturbance - she sees "zigzag shimmering lines" starting near the center of her vision, which gradually expand outward over about 20 minutes, leaving a temporary blind spot. About 10 minutes after the visual symptoms resolve, she develops a severe throbbing headache, usually on the right side. The headache is accompanied by nausea (she has vomited during several episodes), sensitivity to light, and sensitivity to sound. The pain is rated 8/10 and is worsened by physical activity like climbing stairs. Episodes last 12-24 hours if untreated. She retreats to a dark, quiet room during attacks. Her mother and sister also have migraines.
Current Episode:
- Visual symptoms began 45 minutes ago and have now resolved
- Currently experiencing moderate right-sided pulsating headache with mild nausea
- Prefers to keep lights dim in the examination room
Physical Examination:
- Vital signs: BP 118/72, HR 68, T 36.8C
- General: Mild discomfort, photophobic (squints at lights)
- Neurological examination: Completely normal including:
- Mental status: Normal
- Cranial nerves: Pupils reactive, extraocular movements intact, visual fields full, no papilledema
- Motor: 5/5 throughout
- Sensory: Intact
- Reflexes: 2+ and symmetric
- Gait: Normal
Red Flag Assessment:
- Not sudden onset ("thunderclap"): No
- No neurological signs
- No fever or neck stiffness
- Pattern consistent with prior episodes
- Age appropriate for migraine
- No papilledema
Diagnosis: Migraine with typical aura (visual)
Treatment:
Acute Treatment:
- Sumatriptan 100 mg orally at headache onset
- Metoclopramide 10 mg for nausea
- Instructions to treat early for best efficacy
Preventive Treatment (indicated given >4 attacks/month):
- Topiramate 25 mg at bedtime, titrate to 50 mg twice daily over 6 weeks
- Lifestyle modifications: regular sleep schedule, avoid identified triggers (patient notes stress and skipped meals trigger attacks)
Education:
- Keep headache diary to track frequency and triggers
- Limit acute medication use to avoid medication overuse headache
- Return if headache pattern changes
Clinical Course: At 3-month follow-up, topiramate had reduced attack frequency to 1-2 per month. Sumatriptan effectively aborted most headaches when taken early. The patient reported improvement in quality of life with fewer missed workdays.
Clinical Pearl: Migraine aura is a spreading cortical phenomenon (cortical spreading depression) that produces positive visual symptoms (scintillating scotoma with zigzag lines) that gradually expand over 5-60 minutes. This gradual spread distinguishes it from the sudden onset of stroke or TIA. The aura typically precedes the headache by minutes to an hour. Treatment with triptans is most effective when given during the aura or early headache phase before central sensitization develops.