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A 24-year-old woman was referred for evaluation of chronic headaches.  She had had intermittent headaches since age 11. The headaches were initially infrequent, occurring only every 6 months, but approximately 18 months prior to evaluation they became more severe and frequent.  She described more complex symptoms preceding her headache, which included a small area of blur surrounded by a half circle of jagged flashing lights, gradually increasing in size over 15 minutes to encompass the entire left half of the vision of both eyes. In some instances this was followed by numbness and tingling in the left face, arm, and to a lesser degree in her left leg.  The paresthesias were always associated with the visual symptoms.  Headaches were most frequently dull, and throbbing and were most severe at the vertex.  Many headaches were unilateral but some were diffuse. They had a duration of several hours to a few days.  Most were accompanied by light and sound sensitivity. On a few occasions the numbness persisted after resolution of the headache, but in the majority, the neurologic symptoms lasted 30 – 60 minutes, and resolved at the onset of the headache.  She reported occasional episodes of visual obscurations accompanied by facial or arm numbness lasting 30 to>60 minutes that were not followed by a headache.  The headaches and other symptoms markedly interfered with her job and social life.  Review of her headache and symptom diary revealed that most headaches occurred between mid-cycle and the first few days of menstruation.  The review of systems was otherwise unrevealing and her medical history was unremarkable.  Family history did not include migraine.

Physical Examination:            Pulse 82 and regular; respirations 18; blood pressure 118/76.  Chest and cardiac exams: normal. HEENT: normal, head nontender on palpation; neck supple, with good range of motion, no bruits.  Mental status and speech: normal.  Cranial nerves, including funduscopic examination: normal.  Motor and sensory examinations: normal.  Muscle stretch reflexes: normal and symmetric.  Coordination and gait: normal.

 Laboratory Findings:            CBC chemistry with electrolytes, ESR ANA: normal, anti-cardiolipin antibody: normal.  Head CT, brain MRI on two occasions, and cerebral MR angiogram: normal.

QUESTIONS: CASE SUMMARY 3

Question 1: What is the differential diagnosis in a patient presenting with a chronic intermittent heachache and recurrent visual, sensory or motor symptoms?

Question 2: How would you evaluate her as a new patient?

Question 3: What is the most likely diagnosis in this patient?

Question 4: What are the current theories of the pathogenesis of this condition?

Question 5: How could she be treated?