Hits: 0
A 14 year-old girl with known migraines
A 14 year-old girl with a previous history of known migraines occurring twice a year presents with daily
headaches for 6 weeks. The headache is different from her migraine in that it is less intense and not
associated with photophobia or vomiting, but also lying down does not make it better, and may actually
make the pain worse. She has noted that when she coughs her vision dims bilaterally for a few seconds
only. She has been healthy recently with no fever or illness but has gained about 30 pounds over the last
few months. On general exam, she is an overweight young girl with otherwise normal vital signs. On
neurologic exam, she is alert and fluent. Her cranial nerve exam is notable for poor lateral gaze
bilaterally and papilledema on funduscopic exam. Visual acuity is 20/80 bilaterally. She has decreased
recognition of finger movement in the temporal visual fields bilaterally. Motor, reflex, sensory, and
coordination exams are normal.
1) Summarize the case briefly, including neuroantaomic localization and pathogenesis.
2) What is the most likely diagnosis? Name 1-2 alternative diagnoses and discuss briefly why these are
less likely.
3) What additional information (history, exam, laboratory or other studies, consultations) would you
obtain? What laboratory finding would you expect if your most likely diagnosis is correct?
4) Assuming your most likely diagnosis is correct, how would you treat this patient? How would you
monitor his condition and its treatment? What is the prognosis?
A 14 year-old girl with known migraines.
Case 49
A 14 year-old girl with a previous history of known migraines occurring twice a year presents with daily
headaches for 6 weeks. The headache is different from her migraine in that it is less intense and not
associated with photophobia or vomiting, but also lying down does not make it better, and may actually
make the pain worse. She has noted that when she coughs her vision dims bilaterally for a few seconds
only. She has been healthy recently with no fever or illness but has gained about 30 pounds over the last
few months. On general exam, she is an overweight young girl with otherwise normal vital signs. On
neurologic exam, she is alert and fluent. Her cranial nerve exam is notable for poor lateral gaze
bilaterally and papilledema on funduscopic exam. Visual acuity is 20/80 bilaterally. She has decreased
recognition of finger movement in the temporal visual fields bilaterally. Motor, reflex, sensory, and
coordination exams are normal.
1) Summarize the case briefly, including neuroantaomic localization and pathogenesis.
2) What is the most likely diagnosis? Name 1-2 alternative diagnoses and discuss briefly why these are
less likely.
3) What additional information (history, exam, laboratory or other studies, consultations) would you
obtain? What laboratory finding would you expect if your most likely diagnosis is correct?
4) Assuming your most likely diagnosis is correct, how would you treat this patient? How would you
monitor his condition and its treatment? What is the prognosis?