A 43-year-old woman comes to the emergency department due to a 2-hour history of vertigo, occipital headache, and lip numbness. She reports having seen "floating lights" earlier, but her vision was not compromised. The patient has a history of migraine headaches without aura. She does not use tobacco, alcohol, or illicit drugs. Current medications include a combination estrogen-progestin oral contraceptive.
Blood pressure is 130/77 mm Hg and pulse is 98/min. Neurologic examination shows mild dysarthria but is otherwise normal.
MRI of the brain without contrast shows no acute intracranial abnormality.
Which of the following is the most appropriate next step in management of this patient?

Question

A 43-year-old woman comes to the emergency department due to a 2-hour history of vertigo, occipital headache, and lip numbness.  She reports having seen "floating lights" earlier, but her vision was not compromised.  The patient has a history of migraine headaches without aura.  She does not use tobacco, alcohol, or illicit drugs.  Current medications include a combination estrogen-progestin oral contraceptive.
Blood pressure is 130/77 mm Hg and pulse is 98/min.  Neurologic examination shows mild dysarthria but is otherwise normal.
MRI of the brain without contrast shows no acute intracranial abnormality.
Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_9662_613c_853d_c3dcf478e414_MD0002_00 This patient with a history of migraine who presents with an occipital headache, brainstem symptoms, and a normal brain MRI is likely experiencing a migraine with brainstem aura (MBA; previously known as a basilar-type migraine). MBA is a rare subset of migraine characterized by aura with brainstem symptoms (eg, vertigo, dysarthria, ataxia) without motor weakness. It is most common in women with a history of migraine. Diagnosis requires the presence of >2 basilar aura symptoms (shown in the table) that are fully reversible. Occipital headaches may suggest the diagnosis but are not always present. > The symptoms of MBA can mimic dysfunction of the posterior cerebral circulation; differential diagnosis includes transient ischemic attack and basilar aneurysm, as well as temporal lobe epilepsy and benign paroxysmal positional vertigo. As a result, most patients require MRI of the brain and MR angiography of the head and neck to rule out posterior vascular lesions. After vascular lesions have been ruled out, patients can be treated with antiemetics and non-vasoconstricting agents (eg, nonsteroidal anti-inflammatory drugs). Triptans (eg, sumatriptan), beta blockers, and ergotamine derivatives are contraindicated in MBA because they may lead to vasoconstriction and ischemia of the vertebral-basilar system (Choice A). Verapamil is preferred for chronic prevention (Choice E); alternatives include lamotrigine, amitriptyline, and topiramate. (Choice B) Oral contraceptives should be discontinued in patients who experience migraine with aura. However, this patient first warrants additional imaging due to the potentially devastating complications of missed neurovascular disease. (Choice D) Electroencephalogram should be considered to exclude seizure in a patient experiencing MBA with altered mentation, which is not seen in this case. Educational objective: Migraine with brainstem aura is a subset of migraine characterized by vertigo, dysarthria, ataxia, and diplopia. Because the symptoms can mimic posterior circulatory defects, vascular lesions should be ruled out with MRI and MR angiography. __________

A 43-Year-Old Woman Comes to the Emergency Department Due to a 2-Hour