Resident and Fellow Section

CASE PRESENTATION The patient is a 30-year-old woman with a history of classical migraine headaches from ages 10 to 20. Her past headaches involved blurring of the left visual field that would last for about 30 minutes. The patient described the visual symptom as seeing “popcorn” or “TV static.” She would see peripheral spots followed by a short period of nausea. She would then develop a pounding pain over her right temple and right eye. The pain would usually last about 5 hours. It would resolve with sleep. Caffeine triggered her headaches. The patient has had 2 to 3 attacks in the last 10 years. The patient again developed her usual migraine headache symptoms as part of the current presentation. There was a gradual onset of a right pounding headache with an aura of blurred vision and spots in the left visual field. The pain oscillated in severity, resolving almost completely with sleep. It would then return the following day. It ranged from 4 to 8 out of 10 in intensity. She visited an outside hospital emergency department where she was given meperidine with some improvement. She was also given sumatriptan. She states that it decreased her visual symptoms but not the pain. The patient presented to this hospital 5 days after the onset of her continuing headache. Head computerized tomography suggested an arteriovenous malformation. Brain magnetic resonance imaging/ magnetic resonance angiography (MRA) was performed. It showed an approximately 3 cm right medial occipital arteriovenous malformation (Fig. 1), without evidence of prior hemorrhage. The patient received ibuprofen and acetaminophen in the emergency department with minimal effect on her headache. She denied any nausea, but had a headache that was 4 out of 10 in intensity and was again gradually increasing. Her outpatient medications include doxycycline 100 mg po bid and sumatriptan 25 mg po prn headache. Family history is notable in that her mother also has migraine headaches. The patient is a single office worker who rarely drinks alcoholic beverages and does not smoke. Complete blood count, metabolic panel, and coagulation Fig 1.—T2 axial magnetic resonance images revealing R medial occipital arteriovenous malformation. ISSN 0017-8748 doi: 10.1111/j.1526-4610.2009.01563.x Published by Wiley Periodicals, Inc. Headache © 2009 the Author Journal compilation © 2009 American Headache Society