Neurology · Year 3 · from Neurology

Case 1: Migraine with Aura

Patient Demographics

  • Age: 28 years
  • Sex: Female
  • Occupation: Graphic designer

Chief Complaint

"I see zigzag lines before I get a terrible headache."

History of Present Illness

The patient reports episodic severe headaches occurring 3-4 times per month for the past 5 years. Each episode begins with visual disturbances - she sees "shimmering zigzag lines" that start in her central vision and expand peripherally over 20-30 minutes. As the visual symptoms resolve, she develops a unilateral throbbing headache (alternating sides), usually rated 8/10 in severity. Associated symptoms include nausea, occasional vomiting, photophobia, and phonophobia. Episodes last 12-24 hours and are partially relieved by lying in a dark, quiet room. She notes headaches are more frequent around her menstrual period and triggered by stress and lack of sleep.

Neurological Examination Findings

Mental Status:

  • Alert, oriented, appropriate (examined between attacks)

Cranial Nerves:

  • Visual acuity: 20/20 bilateral
  • Visual fields: Full to confrontation
  • Pupils: Equal, round, reactive
  • Extraocular movements: Intact, no nystagmus
  • Face symmetric, sensation intact

Motor Examination:

  • 5/5 strength throughout
  • Normal tone and bulk

Sensory Examination:

  • Intact to light touch, pinprick, vibration, and proprioception

Reflexes:

  • 2+ symmetric throughout
  • Plantar responses flexor bilaterally

Coordination:

  • Finger-to-nose and heel-to-shin normal
  • No tremor

Gait:

  • Normal, tandem intact

Diagnostic Criteria Applied

ICHD-3 Criteria for Migraine with Aura:

  • At least 2 attacks fulfilling criteria B-D
  • One or more fully reversible aura symptoms (visual - YES)
  • At least 3 of: spreads gradually over ≥5 min (YES), symptoms last 5-60 min (YES), at least one symptom is unilateral (YES), aura accompanied by headache within 60 min (YES)
  • Not better accounted for by another diagnosis

Neuro Workup

  • Neurological examination: Normal between attacks - no further imaging required per guidelines
  • MRI Brain (obtained for reassurance): Normal, no white matter lesions
  • This patient does NOT have red flags:
  • No thunderclap onset
  • No fever
  • No new neurological deficits
  • No papilledema
  • No change in established headache pattern

Diagnosis

Migraine with typical visual aura (episodic) - high frequency (approaching chronic migraine threshold)

Management

Acute Treatment:

  1. Sumatriptan 100 mg PO at aura onset or early headache
  2. Naproxen 500 mg as adjunct or alternative
  3. Metoclopramide 10 mg for nausea
  4. Limit acute medication use to <10 days/month to prevent medication overuse headache

Preventive Treatment (indicated: ≥4 headache days/month):

  1. First-line: Topiramate 25 mg, titrate to 50-100 mg BID
  2. Alternatives: Propranolol, amitriptyline, or valproate
  3. Consider CGRP monoclonal antibody (erenumab, fremanezumab) if refractory

Lifestyle Modifications:

  1. Regular sleep schedule (7-8 hours)
  2. Stress management
  3. Regular meals (avoid fasting)
  4. Headache diary to identify triggers
  5. Aerobic exercise 30 min, 3x/week

Menstrual Migraine Prophylaxis:

  1. Perimenstrual naproxen 500 mg BID starting 2 days before expected menses
  2. Or frovatriptan 2.5 mg BID perimenstrually

Clinical Image

Image Description: Artistic representation of a scintillating scotoma (fortification spectra), the classic visual aura of migraine, showing zigzag lines expanding from central vision.

Attribution: Image from Wikipedia Commons, by Bowmans_capsule. Licensed under CC BY-SA 4.0. Source: https://commons.wikimedia.org/wiki/File:Migraine_aura.jpg

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