ISSN 0017-8748 doi: 10.1111/head.12497 Published by Wiley Periodicals, Inc.

Headache © 2014 American Headache Society

Images from Headache A “Lifesaving” Migraine Attack Matteo Fuccaro, MD; Francesco Causin, MD; Nicoletta Freddi, MD; Giorgio Zanchin, MD; Ferdinando Maggioni, MD

Key words: cerebral aneurysm, history, migraine, physical examination Abbreviations: 3D, three-dimensional, ED emergency department, MO migraine without aura, MRA magnetic resonance angiography, MRI magnetic resonance imaging (Headache 2015;55:846-848)

the attending physician if she had other symptoms, she casually reported that she had noticed from about 7-8 months a visual disorder consisting of a slight but persistent loss of sight in her left eye. This disorder had been overlooked by the patient and was not investigated as it was considered irrelevant and age related. Neurological examination was normal, but the ophthalmologist consultant evidenced an uncorrectable loss of visual acuity in her left eye and a small scotoma in the inferior external left quadrant of visual field. The patient was immediately subjected to a brain computed tomography showing the presence of a large aneurysm of the left carotid artery (Fig. 1A). She was admitted to our Department of Neurology and underwent contrast enhanced brain magnetic resonance imaging (Fig. 1B), brain magnetic resonance angiography (Fig. 1C), and 4 vessel cerebral digital angiography (Fig. 1D) that confirmed the aneurysm presence. A few days later, a successful closure of the aneurysm was performed by an endovascular stent-assisted coiling of the aneurysmal sac, without any visual improvement after the procedure (Fig. 2A–D).

Migraine is a common and disabling neurological disorder affecting between 10% and 20% of the general population, with a female to male ratio of 2-3:1.1 There is evidence of a possible comorbidity between migraine and several diseases.2 Furthermore, there is a possibility of a casual association between migraine and many intracranial diseases, as in the case here reported.

CASE REPORT A 51-year-old woman presented to an emergency department (ED) setting complaining of a severe migraine without aura (MO) attack (International Classification of Headache Disorders, 3rd edition, beta).3 She suffered MO attacks about twice a month since she was 35 years old. The patient was otherwise in good health. Occasionally, her attacks were more intense than usual and they were accompanied by intense vomiting. Therefore, she had to be treated with intravenous medications through access to the ED. On one of these occurrences, when questioned by From the Headache Centre, Department of Neurosciences, University of Padua, Padua, Italy (M. Fuccaro, G. Zanchin, and F. Maggioni); Department of Neuroradiology, Azienda Ospedaliera Padua, Padua, Italy (F. Causin); Department of Neurology, Hospital S. Antonio, Padua, Italy (N. Freddi).

Conflict of Interest: None. Financial Support: None.

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Fig 1.—(A) Computed tomography showing, above the sella turcica, a slightly hyperdense, well-delimitated, and oval-shaped area of about 20 mm in diameter, suggestive for a vascular lesion. (B) T1-weighted gadoliniumenhanced brain magnetic resonance image (MRI) and (C) threedimensional (3D) magnetic resonance angiography (MRA) showing a 2 cm aneurysm rising from the ophthalmic segment of the left carotid siphon. (D) Digital angiography showing a large aneurysm of 20 × 18 × 18 mm, involving the ophthalmic tract of left carotid artery, whose dome is turned upward and medially and lifts up both anterior cerebral arteries. A stenosis is present on the carotid siphon, just below the neck of the vascular formation.

Fig 2.—(A) Post-operative digital angiography showing the partial exclusion of the aneurysm and the patency of the main arterial branches after the flow diverter stent and coils positioning. (B) Post-operative fluoroscopy shows the loose packing with 300 cm-long platinum coils, used during the intervention, to partially fill the aneurysmal sac. (C) Threedimensional (3D) magnetic resonance angiography (MRA) and a (D) T2weighted magnetic resonance image (MRI) demonstrating the successful occlusion of the treated left internal carotid artery aneurysm.

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COMMENTS The principal consideration, emerging from the analysis of this case, is the importance of performing an accurate history and physical examination in every patient, even when the disorder appears evident. Moreover, we can say that in this case a severe migraine attack has become an important and probably life-saving gift for the patient! REFERENCES 1. Stovner LJ, Hagen K, Jensen R, et al. The global burden of headache: A documentation of headache

June 2015 prevalence and disability worldwide. Cephalalgia. 2007;27:193-210. 2. Schoenen J, Dodick DW, Sándor PS eds. Comorbidity in Migraine. Oxford: Wiley-Blackwell; 2011. 3. Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia. 2013;33:629-808.

A "Lifesaving" Migraine Attack.

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