Complicated Migraine

Abstract

A 23-year-old medical student presents to the emergency room with moderate to severe right-sided headache over the past 5 days. She reports that nausea and vomiting, as well as phono- and photophobia, accompanied the headache initially. The pain is always present but fluctuates in pain intensity from moderate to severe. It always stays in the described location. Mechanical allodynia has developed over the right scalp over the past couple of days. She also reports that she experienced a gradual onset of visual field disturbances that developed into a right-sided hemianopia over several minutes and slowly resolved over 60 min, with a small residual visual field defect in the left lower quadrant. In parallel to the amelioration of her visual symptoms, she describes slow-onset sensory loss and paresthesia starting with her right hand and progressing to the whole arm within 10–15 min. She also experiences difficulties finding the right words and feels that people seem to misunderstand certain words she is saying. The mild aphasia and sensory symptoms did not resolve and are still present after 7 days on presentation in the emergency room. Her usual migraine attack frequency is once per month, but she never experienced aura before. Her mother suffers from migraine with typical aura, and she has no siblings. Her past medical history is otherwise unremarkable; she has never been to a hospital before and takes no drugs. She is a nonsmoker and does take oral contraception, however.