Migraine Visual Aura

The patient is a 9 year old right handed boy who developed headaches in 1993 at the age of 8. At that time he told his mother that he had bad headaches starting at the back of the head, usually bioccipital, spreading over the top of the head to his forehead. The headaches were short in duration lasting 8 to 15 minutes, responded to Advil, and were accompanied by an unpleasant feeling in his stomach described as nausea. He admitted to photophobia and phonophobia. The headaches were not severe enough for him to lose time from school. He was not seen by a physician at that time. In 1994, he started to complain of transient monocular dimming of vision in his right eye with the objects that he was looking at appearing darker compared to the left eye. There was no loss of vision and no positive phenomena such as photopsias or sparks. At this time, he was referred to an ophthalmologist who documented a normal eye examination. Six months later the episodes of visual dimming OD occurred almost every day, lasting 1 to 2 minutes with full recovery. His pediatrician was consulted and found no abnormality on examination. In 1995 he was referred to a pediatric neurologist because the episodes of dimming of vision now involved both eyes and he complained of loss of vision. The neuropediatrician diagnosed migraine and obtained a brain MRI to rule out an arteriovenous abnormality of some other cerebral cause because: 1. There was no family history of migraine and 2. Headaches were provoked by exertion. The MRI with Gadolinium was normal. An electroencephalogram was normal. RE: Stress: The patient correlated his attacks of visual dimming, with or without headache, to "a bad day at school". He said "everyday is a bad day" and he defined ‘a bad day' as due to: •His fellow students fighting •Boys make fun of him because he has scar tissue on his face following removal of a birth mark •Boys get annoyed with him because he tells them he can't play with them because his eyes are bad. •Other boys think he is stupid because he has bad eyes •They think he is making it up that he has bad eyes. •Also, there is a troublemaker in school and he makes it uncomfortable for all the kids. Kyle likes school and he is in the top 3 in his class. He likes math and science and hates reading and spelling. He is not known to be dyslexic. He is good at sports, plays soccer and basketball. He had two headaches provoked by running. His headache is not precipitated by excitement but more by anxiety. He was referred for evaluation in 1995 and was very articulate in describing his migraine attacks. He classified them as follows: 1.Visual aura alone lasting less than 5 minutes 2.Visual aura for 5 to 10 minutes followed by headache lasting 10 minutes up to 1 hour. 3.Headache alone, average 1 per month lasting 1 hour By 1995, he was experiencing a stereotypic visual aura of a bright light in the center of his visual field "like a bright light bulb". The light bulb seemed to flash on and shimmer and occasionally around the edge of the bright "sunlight" he saw "little sparks". The hallucination looked "like a sparkler going off in front of him"'. He was unable to see past it. He was not frightened by the attacks of visual aura because he knew from experience that his vision would return to normal. RE: Therapy: The approach to therapy was: 1. His mother met with the school teacher in charge of his class to alert her regarding the stressful situation at school. 2. Inderal 20 mg 1 tablet at 7 a.m. before he went to school, 1 tablet at 4 p.m. daily. After a reduction of stress at school and starting on Inderal, the frequency and severity of his headaches improved. See also: http://content.lib.utah.edu/cdm/ref/collection/ehsl-shw/id/56