Clinical reasoning: Unusual headaches.

Maria Joana Osorio, MD Poonam Bhatia, MD Giulio Zuccoli, MD Deborah Holder, MD SECTION 1 A 14-year-old girl presented to the neurology clinic complaining of headaches. She described her headaches as mild (intensity 3/10), holocranial, and pounding in character. There was no nausea or vomiting, or photophobia or phonophobia. The patient described in detail a sequence of symptoms from the onset of her headaches. First she experienced “funny vision changes in her right eye” characterized by a very bright spinning colored wheel and scotomas. These visual experiences gave rise to right leg numbness, lasting a total of 45 seconds. Following the leg numbness, only the headache would persist, for no longer than 5 minutes. The patient reported no change in consciousness during these symptoms. These episodes started 6 months prior to the patient’s presentation at the neurology clinic and had progressed with increased frequency from monthly to weekly. In between the episodes, she had no complaints. There was no history of head trauma and the patient’s past medical history was unremarkable. Family history was only significant for a maternal cousin with migraines. The patient’s general and neurologic examination findings were normal. She was asymptomatic during the examination.