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Double vision vertigo and bilateral consciousness
A 16 year-old presents to her pediatrician complaining of monthly episodes of double vision, vertigo, and
bilateral consciousness. The symptoms come on over the course of 5-10 minutes and resolve within an
hour. About a half hour after the symptoms start she develops severe pulsating occipital head pain that
lasts for 10 hours and resolves with sleep. She has photophobia and phonophobia with the headache.
The attacks have been occurring for the past three years and have not changed. They are most likely to
occur with her menstrual period. Her mother and sister get similar attacks. Neurological examination is
normal.
1) Summarize the case briefly, including neuroanatomic 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 findings would you expect if your most likely diagnosis is correct?
4) Assuming your most likely diagnosis is correct, how would you manage this patient? Include doses
for one medication you might prescribe, along with an estimate of the cost of a month of your
proposed therapy. How would you counsel the patient about her condition and about any proposed
therapy?
Case 25
A 16 year-old presents to her pediatrician complaining of monthly episodes of double vision, vertigo, and
bilateral consciousness. The symptoms come on over the course of 5-10 minutes and resolve within an
hour. About a half hour after the symptoms start she develops severe pulsating occipital head pain that
lasts for 10 hours and resolves with sleep. She has photophobia and phonophobia with the headache.
The attacks have been occurring for the past three years and have not changed. They are most likely to
occur with her menstrual period. Her mother and sister get similar attacks. Neurological examination is
normal.
1) Summarize the case briefly, including neuroanatomic 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 findings would you expect if your most likely diagnosis is correct?
4) Assuming your most likely diagnosis is correct, how would you manage this patient? Include doses
for one medication you might prescribe, along with an estimate of the cost of a month of your
proposed therapy. How would you counsel the patient about her condition and about any proposed
therapy?