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This woman with recurrent, unilateral headaches associated with nausea and paresthesia (ie, numbness, tingling) of her extremities 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 women are affected more frequently than men. Up to 25% of patients also develop focal, reversible neurologic symptoms that precede or accompany the headache, known as an aura. Symptoms of aura may include visual (eg, wavy lines, visual loss), sensory (eg, paresthesia, numbness), auditory (eg, sounds, hearing loss), and motor (eg, tremors, weakness) dysfunction. Women with migraine, particularly those associated with aura, are at increased risk of ischemic stroke. This risk is magnified for patients on estrogen-containing contraceptives (eg, combined estrogen/progestin pill, vaginal ring, transdermal patch), which increase the risk of thrombosis by altering hemostasis. Therefore, estrogen-containing contraceptives are contraindicated in patients with a history of migraine with aura and should be discontinued immediately. (Choices A, E, and F) Further management of migraine includes abortive therapy (eg, nonsteroidal anti-inflammatory drugs, triptans) to treat acute attacks, and preventive medications (eg, selective serotonin reuptake inhibitors, propranolol) for those with frequent, debilitating symptoms. Although these options should eventually be considered for this patient, she is at elevated risk of stroke while on an oral contraceptive, and the prompt discontinuation of this medication should precede other management. (Choice C) Measurement of cerebrospinal fluid pressure is used to diagnose idiopathic intracranial hypertension (ie, pseudotumor cerebri), which causes headache and nausea in young (usually overweight) women. However, it is typically associated with diplopia and papilledema on exam. Aura (eg, paresthesia) is unexpected. (Choice D) MRI of the brain is indicated to evaluate for mass lesions, stroke, or transient ischemic attack. Although these can cause headache, a tumor usually causes neurologic deficits and progressive headache, whereas stroke typically causes negative symptoms (eg, weakness). Symptoms would not be expected to remit and recur every few weeks. LAST MINUTE TIP 👇👇 Migraine is an episodic neurological disorder that results in severe, unilateral, throbbing headaches often associated with photophobia, phonophobia, and nausea/vomiting; they may be accompanied by aura (focal, reversible neurologic symptoms that precede or accompany the headache). Estrogen-containing contraceptives are contraindicated in patients with migraine with aura due to the increased risk of ischemic stroke.

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A 36-year-old woman comes to the emergency department due to severe headache and vision disturbance. The symptoms began abruptly an hour ago, and since then she has also felt weak, dizzy, and nauseated. The patient has had no similar symptoms in the past. Medical history is significant for a prolactinoma diagnosed a month ago, which is being treated with cabergoline. She does not use tobacco, alcohol, or illicit drugs. Temperature is 37.6 C (99.7 F), supine blood pressure is 80/50 mm Hg with a decrease to 60/40 mm Hg on standing, and pulse is 110/min. On physical examination, the patient appears anxious and in moderate distress. There is mild ptosis and impaired adduction on the right. Bitemporal hemianopsia is present. Bilateral upper and lower extremity muscle strength and sensation are normal. The neck veins are flat, heart and lung sounds are normal, and there is no abdominal tenderness or extremity edema.

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