Case Presentation
A 55-year-old man with a known history of migraine headaches without aura, hypertension, hyperlipidemia, obesity, and newly diagnosed type 2 diabetes mellitus was referred to the Emergency Department (ED) by his ophthalmologist.
Symptoms
- He described the quality of his headache as lancinating, continuous, and pulsatile.
- He described his visual distortions as having a “wavy quality” with associated kaleidoscopic patterns, flashes of shadows, and scintillating scotomas (red and green circles), occurring every 15–20 min and lasting 2 min each.
Medical History
- 30-year history of migraine without aura
- The patient had a 5-day history of visual disturbances and a severe left parietal headache.
- He reportedly received chiropractic manipulation hours earlier in the day prior to the onset of his symptoms.
- The frequency of his typical migraine headaches occurred one to two times per year.
Physical Examination
- The onset of his symptoms was associated with nausea, vomiting, and intermittent sensitivity to light.
- He denied sensitivity to sound or smell, or other neurologic deficits including slurred speech, double vision, focal weakness, numbness, lacrimation, painful eye movements, or nuchal rigidity.
Neurologic Examination
- Right superior homonymous quadrantanopia with 20/25 visual acuity in both eyes, full ocular motility, and unremarkable funduscopy.
- His visual field was also obscured in the right hemifield, more so in his right superior quadrant.
Laboratory Findings
- The initial work up included computed tomographic angiography (CTA) of the head and neck, contrast-enhanced magnetic resonance imaging (MRI) of the brain and orbit with and without contrast and blood work including erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and complete blood count (CBC), were all normal.
Medical Advice
The patient was discharged from the ED with resolution of his headache and visual symptoms. He was advised to obtain a contrast enhanced MRI Orbit with and without contrast and follow up at the in ophthalmology and neurology clinics in 1 week.
- He returned to the hospital 5 days later due to more frequent episodes of visual distortion.
- He reported that the headache was no longer prominent compared to his initial presentation a week prior and the visual field deficit had resolved.
- Electroencephalogram (EEG) was suggested given the unremarkable results of the previous workup and his persistent visual symptoms.
- An initial short-term EEG was normal. A typical event was captured during the long-term recording.
- Ictal EEG demonstrated a left occipital-onset focal seizure with right hemispheric involvement as it evolved.
Treatment
- He was loaded with levetiracetam 2000 mg intravenously with a daily maintenance oral dose of levetiracetam 750 mg twice daily. On this regimen, he continued to report several episodes of the visual disturbance the following next day.
- He was switched to valproic acid (loading dose of 2000 mg and maintenance dose of 500 mg twice daily).
- A repeat routine EEG the following day was normal.
Follow Up
Upon his 2-month follow up with neurology, he reported resolution of the headaches and visual disturbances.
Discussion
The diagnostic criteria as set out by the ICHD-III for migralepsy and other syndromes with migrainous and ictal features remain confusing for practitioners as there is much overlap in clinical manifestations of these entities. EEG should be obtained when ictal features are noted among patients presenting with headache.