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Case Presentation
Seniha Ozudogru, MD
Headache Fellow
17 y/o male
Referred for: Treatment of Prolonged Aura
• Headache History:
–
–
–
–
Family history of migraine
First headache age 6
First migraine 8th grade, migraine without aura
Few months later with visual aura
• Visual aura--blank spot in the center of his vision and
flashing lights in peripheral vision for 20 minutes then
severe headache lasted 9 hrs
• Now has migraine with aura once a year
Migraine without aura every 6 months
• Sumatriptan helped but caused chest tightness
New Visual Symptoms since 2014
• Silvery lines: everyday, up to 12 times in a day.
Lasts for 1 to 2 hours, but always present when
he concentrates on them
• Floating and squiggly lines daily lasting 1 to 2
minutes, 5-10 episodes per day; seen when he
looks at the sky or snow
• Grainy vision all the time, as long as he can
remember
– Visual symptoms are not associated with headache
– Sees through the visual phenomenon
– Visual changes do not affect his driving
PMH
Examination
• Mild head trauma as a child;
deviated septum surgery
• Medications: multiple
vitamins, Claritin and
ibuprofen prn
• SH: Senior in high school;
Good student
• ROS: positive for occasional
difficulty sleeping and mild
light sensitivity all of his life
• VA 20/25 OU; VF normal
• Discs normal
• Neurological examination
normal
• MRI without contrast
normal
• PHQ-9: 4 (minimal
depression)
• GAD-7: 3 (no anxiety)
Differential Diagnosis
•
•
•
•
Migraine with aura
Persistent Aura without infarction
Migraine Aura Status
Visual Snow
• Migraine with Aura (ICHD- 3-beta code 1.2.1)
- Unilateral dynamic visual symptoms gradually developed
and last in 5-60 minutes.
– Migraine aura results from CSD in visual cortex (Hansen et al.
Brain 2013)
• Prolonged aura
– Duration >60 mins, very rarely more then 4 hours (Viana et
al. Cephalalgia 2016)
• Persistent Aura Without Infarction (ICHD- 3-beta code
1.4.2)
– Typical visual aura in a patient with Migraine with aura
that lasts for longer than 1 week. Neuroimaging shows no
infarction.
• Migraine Aura Status (ICHD-3-beta in appendix A1.4.5)
– Typical visual aura in a patient with Migraine with aura,
two aura episodes per day occur in at least 3 days.
Proposed Criteria for Visual Snow
Schankin et al.Brain 2014 137; 1419- 1428
• Visual snow: dynamic continuous tiny dots in the
visual field for at least 3 months
• Presence of at least 2 additional visual symptoms
– Palinopsia: at least one of the following:
• Persistent or trailing after image (different from retinal after image)
– Enhanced entoptic phenomenon (at least one of the following:
excessive floaters, self light of the eye, photopsias
– Photophobia
– Nyctalopia (impaired night vision)
• Symptoms not consistent with typical migraine aura
• Symptoms not explained by another disorder
We
showed
him these
pictures
And he
thought B,
C, E all
looked
like what
he saw!
Schankin et al . Brain. 2014 May;137(Pt 5):1419-28.
Treatments after the correct diagnosis
• Reassurance
• Treat underlying migraine- we prescribed
Almotriptan (Keam, SJ et al. Drugs 2002)
• Medication doesn’t always work
• Reported meds: lamotrigine, nortriptyline,
carbamazepine, sertraline(Schankin et al Headache. Jan 2017)
• Blue-yellow spectrum filters (Lauscke et al J Clin
neuroscience 2016)