Headache-Adviser.com

Basilar Migraine Diagnosis

by Maureen Moran
(Naperville, Il)

Basilar Migraine Symptoms

Basilar Migraine Symptoms

Hello Mary Kay!
My 16 year old son went completely blind in both eyes for approx. 5 minutes during a shower prior to school one month ago. He also had neck pain and a sudden headache with the blindness. His pupils were very dilated for approx. 40 minutes during and after blindness.It took twenty minutes for his vision to completely return to normal. This was not a vagal event. He was alert and oriented during the whole event.

That day he had a CT without contrast that was negative. He also had A brain MRI and neck MRA/MRI, that was essentially negative. A 2-D echo was also negative for PFO. LABS including ESR and CRP were normal.

We were scheduled to repeat the MRI in a few weeks because there was an area of mild enhancement in the tentorium cerebelli on MRI. The working diagnosis was opthalmic migraine. However, my son had a fever, nausea/vomiting, and respiratory type virus this week. Three days into this, (Yesterday morning )he woke up and took a shower. He went completely blind again for 1 minute. Pupils very dilated again. He also complained of headache and neck pain again. All symptoms resolved in 2-3 minutes. He was awake and alert through the whole event and did not pass out.



Our pediatrician put him in the hospital for further evaluation this time. No new MRI was done. The previous scans were reevaluated. After the eval, a neurologist and neuro-opthalmologist both felt that this probably is a basilar migraine. We have no history of migraines in the family. My son has never had headaches or visual problems in his life. He has dealt with asthma, GERD, seasonal allergies and sinusitis in his lifetime. He takes Advair once daily and claritin once daily. He is a very active and happy kid. He denies any use of nutritional substances or drugs and I believe him.

I am worried, especially with him driving right now. I have practiced as a physician assistant in cardiac and vascular surgery in the Chicago area for 20 years. What is the best preventative treatment in this setting? Thanks for any help!

Answer:

Hi Maureen,

I can understand your aprehension..I see many parents of teens with a new onset of atypical headache and they are usually a bit frightened. Sometimes I think we have it worse with all our medical knowledge and how much we know and can then worry about.

In reviewing what you wrote, I do not see and MRA of the brain, only the neck. I would assume this was done. One thing to consider also in a differential diagnosis of basilar migraine is that most cases initally present like vertebral-basilar insufficiency. This sounds like your son, especially the reversible blindness. I would consider adding a transcranial doppler to verify basilar and vertebral artery velocities and flow.

If all the symptoms occurred together and were fully reversible then it does indeed sound like basilar migraine. Dysarthria and paresthesias are also common with this type of migraine, and they usually occur in teens or young adults.

What confuses many is that pediatric forms of migriane are usually shorter than adult. Theirs are 1-2 hours usually while adults are 4-72 hours. The good news is that your son has a 50% chance he will grow out of this, unlike girls who carry headaches longer.

Preventative treatment for this is Verapamil 120 to 240 mg qd. If he cannot tolerate that then I would go to propranolol (unless he still has asthma) starting at 20mg and move up to 80 if needed.

These patients cannot have triptans unfortunately, nor ergotamine (Migranol nasal spray). Since they are short headache syndromes, the best treatment is prevention. You can read more here.

Best of luck!
Mary Kay Betz MS RPA-C

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Ocular Migraine Symptoms

by Caroline
(Netherlands)

Scotoma of Ocular Migraine

Scotoma of Ocular Migraine

Hello there,
I ask because my doc called it a migrain when I had a certain symptom but I had no other problem than the symptom!
Four times now, over maybe three years, but twice in the last six months, I've had a gradually appearing 'zigzag circle' in the centre of my right eye that stays for around an hour. It makes it difficult to see, so I close my eyes, and can still see it.

I'm forced to lie down really as I can't focus properly. It sort of flashes and moves about when I try to look right at it. Last time, I took aspirin/paracetamol/caffeine and it gradually went away.

I saw the doctor after the first time and that's when he said 'probably a migrain' but I didn't have any sort of headache with it. I thought maybe I'd been on the computer too long... or lay in bed reading too long... but the last time it was there when I awoke, and I'd been up for a few minutes, a couple of hours earlier with no problem.

I know migraines can come with flashes and eye problems and wonder if that's why the doctor associates this with migraine but I just don't really believe that it can be called that without pain (although, thank goodness if that's the case!) so wonder if you have heard of this before?

Much obliged for your answer.
Caroline
Almere, Netherlands

Answer

Hello Caroline,

What you are describing is a type of migraine known as an ocular migraine. Although a little rare, they do exist. We also call it "aura without migraine", opthalmic migraine and even "eye" migraines.

If they are frequent, we do tend to treat them with a type of drug called a beta-blocker. If they are episodic and occur only a few times a year, I would not worry about them. There really is nothing to take at the onset, you just have to let them play out until they are over.

You can read more about ocular migraine here.

Take care...

Mary Kay Betz MS RPA-C

Comments:

THANKS! what a great answer!

I'm so impressed!
Very comprehensive, understandable and relieving. I'll be keeping an eye on things and now know what to tell my doctor when (if) I feel I need any meds.
Thank you.

Caroline

Answer:

You are quite welcome..good luck!

Mary Kay


What I did:

The image depicts perfectly what I saw, though mine was off to the far right. I cut out caffeine (in steps, from 2 caffeine-rich drinks a day) and now drink decaf coffee and herb tea. From getting 3 episodes a week, I now get none.

I never thought I could omit caffeine from my life but the experiment to get rid of the ocular migraine episodes has paid off.

Answer:

Thanks for the tip..interesting. I have not had a patient say this but we always recommend no more than one cup of caffeine (coffee or soda) per day in a headache syndrome.

Mary Kay

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Atypical headache

by Jerelynn
(Saugertie, New York USA)

 Headache On Side Of Head

Headache On Side Of Head

Hi, I'm 55 yrs. old woman, no history of headaches. Have had one for 1 1/2 months. Am seeing a neurologist, did MRI, MRA, MRV, test for Lymes, and ESR test, all normal. Cat Scan showed a small menginoma. Neurologist suggested Depakote then Inderal but I don't like taking drugs and have MVP with a scheduled appt with a cardiologist coming up.



Started taking Neurontin 2 days ago, 300 mg twice a day. Not sure it is doing anything, is it too early to expect results from it?

The headache is pretty much always on top right and side, not pounding. Also sort of wierd nervy type stuff above my eye and into my cheek sometimes. Had my eyes tested today, no problems.

I had major anxiety about this which I know didn't help. But I've been fairly calm this week and have been trying to go about my business as usual.
Any thoughts would be appreciated.

Answer:

Hi Jerelynn,

I had to look you up on a map to find Saugerties and I see you are south of Albany. Unfortunately, there are no headache centers in Albany, the closest is Manhatten Headache Center with Dr. Mauskopf.

A new onset of daily headache should be worked up the way yours was and if thyroid is also normal, the only bloodwork I would have added is a Vitamin B-12 level.

Your neurologist chose the best drugs for daily headache..Depakote or Elavil are great. With an MVP, Inderal is very appropriate..neurontin however is not. It very rarely treats any type of headache well and is usually used for diabetic neuropathy.

Headaches right on top of the head and on one side are usually coming from the neck. Spasms can influence the scalp muscles and cause headache. If this is the case I would definitely recommend a few weeks of Elavil, low dose, 10mg at night and physical therapy. Try to get around the idea of not taking drugs as sometimes they really help. You are still in the acute phase of this pain, but if you get beyond 6 months without relief then you might move into chronic daily headche.

Have your neurologist check the neck for spasms and trigger points.

Good luck!

Mary Kay Betz MS RPA-C

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Temporal Arteritis And Headaches

by Tony
(Southern California)

Headaches In The Elderly

Headaches In The Elderly

My 80 year old mom has painful and long-lasting cluster headaches almost every morning. She has diabetes, anemia, temporal arteritis, occasional UTI, and other conditions. We understand that most meds can cause headaches, insomnia, drowsiness, fatigue, etc, and hypoxemia and hypoglycemia may play a part. She also has meds for depression and Risperdal for hallucinations. I'm not asking for consultation on any of that.

I am wondering if all of her doctors are missing obstructive sleep apnea as a possible cause of the headaches. She doesn't sleep a lot at night, but when she does, she's loud and her breathing seems labored. From what I've read, it's possible that some of her other ailments might be caused by OSA and the resulting headaches, and treatments with Botox, Tylenol, and other remedies might be missing the mark entirely, though they are effective for some amount of time.

We're in southern California (Hoag Hospital area). Can you recommend a place where testing or studies are done in this area so that we can get a diagnosis for possible OSA or a similar condition which might be causing or exacerbating the headaches? If we can get the headaches properly treated, some of the other issues may become less problematic as a consequence - right now, there doesn't seem to be much relief for this poor woman.

Any other suggestions are welcome.

I've tried to keep this short and focused but I'll be happy to provide more info if required. Thanks!
Tony

Answer:

Hi Tony,

First of all I am unsure if your mother really has cluster headaches as they are somewhat rare and almost never occur in the elderly. When I see them, they occur seasonally in men in their 50's and I have one or two women with them but again much younger. Cluster headaches are painful, short (less than 120 minutes) and associate with a red eye and tearing of the eye with nasal congestion.

Temporal arteritis however, does occur in the elderly.

Sleep apnea headaches do occur at any age (even children) first thing in the morning are either across the forehead or all over the head. They are dull, diffuse and usually resolve within a few hours as the brain gets more oxygen. You are right..hypoxemia is the cause and can be aggravated by anemia.

This is a link to the headache center at USC. If your mom is not seeing a headache specialist she should as she is a complex case. Headache is now a board certified speciality of neurology. If you prefer you can discuss this with her neurologist, as he or she can order out the sleep study.

I see there is also a Headache Center in Newport Beach and if you can get your mom in there I would start with them..talk about the snoring they will take it from there.

Good luck!
Mary Kay Betz MS RPA-C


COMMMENTS:

I thank you kindly for your fast and helpful response.

I used the term "cluster" to define the motion of the headaches from one part of her head to others, but assigning a clinical name to an observation was not appropriate on my part - thanks for setting that straight.

Her neurologist recently gave her Botox injections since we've tried other ineffective remedies recently. We know this works but have been putting it off, trying to identify the real cause of the problem, but we're all agreed that sometimes "relief" is better than finding and fixing a problem at its roots. We expect this to start working soon and to help for 6-12 months based on her previous experience.

We'll need to avoid multiple simultaneous remedy trials, but we'll certainly check into the other local resources you've referenced. I'll post here at a later time to let everyone know how things go. Cost and insurance will certainly be factors to be considered.

BTW, the temporal arteritis is being treated with Methotrexate, the dosage of which changes based on the sed rate. I don't know if doctors are aware of this dynamic, but the sed rate seems to drop incredibly with shots of Procrit for anemia. Increased dosage of Methotrexate itself causes headaches, so less is always better. Two birds, one stone. Good when you can get it. May help someone.

Hi Tony,

Best of luck to your Mom with the Botox. I am seeing about the same response rate as reported in the literature..75% and I do about 2-3 Botox patients a week who have not responded to other therapies.

I had suspected you were using the term "cluster" to describe her symptoms. Many people do that.

If all else fails, consider looking for a headache center that offers inpatient treatment for severe cases. I believe Diamond in Chicago does it, Michigan Head and Pain and Jefferson in Philadelphia also offer this. I am unsure of west cost options.

Mary Kay


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