An 11-year-old girl is brought to the emergency department for visual disturbances. Two hours ago, the patient saw flashing lights followed by spots of vision loss. These symptoms fully resolved within 30 minutes. Since then, a bifrontal, throbbing headache and nausea have developed. The patient has had no fever, eye pain, or head trauma. She has had two similar headaches in the last 6 months. Temperature is 37.2 C (99 F), blood pressure is 102/68 mm Hg, and pulse is 88/min. On examination, the patient is alert and appears in moderate discomfort with her eyes closed. Extraocular movements are intact. Funduscopic examination is normal, and pupils are equal and reactive to light, but the patient is uncomfortable during assessment due to the light. Cardiovascular, respiratory, abdominal, and neurologic examinations are normal. Which of the following is the best next step in management of this patient?

Question

An 11-year-old girl is brought to the emergency department for visual disturbances.  Two hours ago, the patient saw flashing lights followed by spots of vision loss.  These symptoms fully resolved within 30 minutes.  Since then, a bifrontal, throbbing headache and nausea have developed.  The patient has had no fever, eye pain, or head trauma.  She has had two similar headaches in the last 6 months.  Temperature is 37.2 C (99 F), blood pressure is 102/68 mm Hg, and pulse is 88/min.  On examination, the patient is alert and appears in moderate discomfort with her eyes closed.  Extraocular movements are intact.  Funduscopic examination is normal, and pupils are equal and reactive to light, but the patient is uncomfortable during assessment due to the light.  Cardiovascular, respiratory, abdominal, and neurologic examinations are normal.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d579_5c59_bc81_d50ac9efac7a_MD0003_00 This patient likely has migraine headaches, which present with episodic headaches lasting several hours to days. The pain is typically described as throbbing or pulsatile and is unilateral or, in children, bifrontal. Nausea, vomiting, photophobia, and phonophobia are common. Funduscopic examination may elicit pain due to exposure to bright light, as seen in this patient. Some patients may experience an aura before the headache. Visual auras are most common and may include scintillating scotoma or bright, flashing lights. Sensory auras can present with facial or unilateral extremity numbness or weakness. Auras typically last <1 hour, and patients are neurologically intact afterward. scintillating scotoma Migraine is a clinical diagnosis and does not warrant diagnostic evaluation (eg, neuroimaging) if neurologic examination is normal. First-line treatment includes supportive care (eg, lying in a dark, quiet room with a cool cloth on the forehead) and simple analgesia (eg, acetaminophen, nonsteroidal anti-inflammatory drug [eg, ibuprofen, naproxen]). Refractory headaches are typically treated with oral or intranasal triptans. (Choice A) Neuroimaging (eg, CT scan of the head, brain MRI) to exclude a mass is indicated in patients with abnormal neurologic examination (eg, weakness), signs of increased intracranial pressure (eg, papilledema, nighttime wakening due to headache), or rapidly increasing headache frequency. None of these features is present in this patient. (Choice B) Acute angle-closure glaucoma, which is due to increased intraocular pressure, can present with headache and obscurations (eg, halos around lights). Severe eye pain, poor pupillary reactivity to light, and conjunctival redness are common and not present in this patient. (Choice C) Lumbar puncture is warranted for features of meningitis, such as headache with fever and nuchal rigidity. In contrast, this patient is afebrile with a normal examination. (Choice E) Brain masses (eg, pituitary adenoma) compressing the optic chiasm can cause visual field defects (eg, homonymous hemianopia), but visual symptoms would be persistent. In addition, idiopathic intracranial hypertension can cause headache, transient visual obscurations, and visual field defects, but papilledema would be expected on examination. Educational objective: Migraines in children typically present with unilateral or bifrontal pain, photophobia, phonophobia, nausea, and vomiting. If present, the aura is most commonly visual (eg, flashing lights, scintillating scotoma). Diagnosis is clinical, and first-line treatment includes acetaminophen or a nonsteroidal anti-inflammatory drug. References: Pharmacological treatment of acute migraine in adolescents and children. (http://www.ncbi.nlm.nih.gov/pubmed/23575981) Drugs for the acute treatment of migraine in children and adolescents. (http://www.ncbi.nlm.nih.gov/pubmed/27091010)

An 11-Year-Old Girl Is Brought to the Emergency Department for Visual