MKSAP Quiz: recurrent visual disturbance, headache
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A 62-year-old man is evaluated for recurrent episodes of visual disturbance followed by headache every 2 to 3 months for the past 5 years. The visual disturbance is described as a shimmering of light that obscures both visual fields and seems to resolve over 25 minutes and that is followed by mild to moderate headache with mild nausea. The headache typically resolves without treatment in 12 to 24 hours. The spells occur without reference to change in bodily position or time of day. He has a distant history of mild headaches with nausea, which he cannot recall clearly. Physical examination is normal.
What is the most likely diagnosis?
A. Vertebral-basilar transient ischemic attack
B. Cluster headache
C. Migraine without aura
D. Thunderclap headache
E. Migraine with aura
MKSAP Answer and Critique
The correct answer is E) Migraine with aura. This item is available online to MKSAP 14 subscribers in the Neurology section, Item 18.
This patient has a distant history of migraine without aura, but his current headache meets the criteria for migraine with aura. Although vertebral-basilar transient ischemic attack could produce episodes of visual disturbance and headache, the episodes tend to be of shorter duration and worsen in frequency and severity over time. In addition, such episodes may be associated with postural change and should also be associated with other posterior circulation deficits, such as diplopia, vertigo, and dyscoordination. This patient has had the same frequency and severity of attacks over 5 years and does not relate other features consistent with posterior circulation disease. However, if this patient had presented without the 5-year history of similar events, then an evaluation for vertebral-basilar insufficiency should be considered.
Cluster headache is a brief headache and is generally not associated with visual disturbance. Thunderclap headache comes without warning and is a severe-intensity headache of sudden onset and remission, which does not fit this patient's description. This patient has a description of migraine with aura. It is not unusual for patients with distant migraine histories to change in later years to other forms of migraine, including the remission or initiation of migraine aura.
Key Point
- Approximately 20% of patients with migraine have headache with aura, that is, neurologic problems such as visual hallucinations or numbness or tingling before or during headache.