A 22-year-old woman comes to the emergency department due to acute vision disturbances and headache. About an hour ago the patient experienced a small area of visual loss, which she describes as a hole in the visual field. The vision disturbance gradually expanded to a C-shape in her peripheral vision and spontaneously resolved after 15-20 minutes. A progressively worsening, severe, right-sided headache of pulsating quality quickly followed. The patient has had similar headaches in the past but not of such severity. She has no other medical conditions and takes no medications. Blood pressure is 150/86 mm Hg and pulse is 92/min. On physical examination, the patient is lying still in bed with eyes closed. The pupils are equal and reactive to light. Funduscopic examination reveals no abnormalities. Bilateral upper and lower extremity muscle strength, deep tendon reflexes, and sensation are normal. Which of the following is the most likely diagnosis?

Question

A 22-year-old woman comes to the emergency department due to acute vision disturbances and headache.  About an hour ago the patient experienced a small area of visual loss, which she describes as a hole in the visual field.  The vision disturbance gradually expanded to a C-shape in her peripheral vision and spontaneously resolved after 15-20 minutes.  A progressively worsening, severe, right-sided headache of pulsating quality quickly followed.  The patient has had similar headaches in the past but not of such severity.  She has no other medical conditions and takes no medications.  Blood pressure is 150/86 mm Hg and pulse is 92/min.  On physical examination, the patient is lying still in bed with eyes closed.  The pupils are equal and reactive to light.  Funduscopic examination reveals no abnormalities.  Bilateral upper and lower extremity muscle strength, deep tendon reflexes, and sensation are normal.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

This young woman with a pulsating, unilateral headache preceded by visual field loss has migraine with aura. Migraines are an episodic neurological disorder that results in severe, unilateral, throbbing headaches often associated with photophobia, phonophobia, and nausea/vomiting. Migraines typically last 4-72 hours and have a strong genetic predisposition; women are affected more frequently than men. Migraines are thought to be triggered by a self-propagating wave of depolarization spreading across neurons in the cerebral cortex, resulting in activation and sensitization of trigeminal nerve nociceptors. Up to 25% of patients also develop focal, reversible neurologic symptoms that precede or accompany the headache, known as an aura. Auras may be due to the spread of depolarization into other areas of the brain, where they are interpreted as "positive" (eg, bright spots, noises, paresthesia, movements) or "negative" (eg, vision/hearing/sensation loss) symptoms. Auras typically develop progressively over a period of minutes. (Choice A) Acute angle-closure glaucoma causes headache and decreased vision associated with elevated intraocular pressures. However, patients are typically older (age >60), and severe eye pain and conjunctival erythema are common. Vision would not be expected to improve without intervention. (Choice B) Cluster headache causes severe unilateral headaches; however, ipsilateral autonomic symptoms (eg, lacrimation, rhinorrhea, flushing, diaphoresis) are expected. The disease is also more common in men and is not associated with aura. (Choice D) Optic neuritis is a demyelinating disorder that causes vision loss, but it is typically unilateral and progresses over a period of weeks. Patients have eye pain that is worse with movement, color vision is often affected, and an afferent pupillary defect is present. (Choice E) Simple partial seizure may be preceded by an aura, but seizures typically cause positive symptoms (eg, lip smacking, arm movement, seeing bright lights) rather than the negative symptoms seen in this patient, and typically last <2 minutes. Unilateral headache is more suggestive of migraine with aura. (Choice F) Transient ischemic attacks (TIAs) also cause focal neurologic deficits; however, these typically have an acute onset, with maximal symptoms at onset rather than the progressive visual field deficit seen in this patient. In addition, TIAs typically occur in older patients with vascular risk factors (eg, smoking, hyperlipidemia) and would be very uncommon in an otherwise healthy young woman. Educational objective: Migraines are an episodic neurological disorder that results in severe, unilateral, throbbing headaches often associated with photophobia, phonophobia, and nausea/vomiting. Migraines typically last 4-72 hours, and up to 25% of patients also develop an aura (focal, reversible neurologic symptoms that precede or accompany the headache).

A 22-Year-Old Woman Comes to the Emergency Department Due to Acute