Migraine with persistent visual aura.

CLINICAL HISTORIES Case 1.—This 74-year-old woman was referred by an ophthalmologist with an 8-week history of squiggles in her left field of vision of both eyes inferior more than superior. During the day, if her eyes were closed, she would see kaleidoscope-type letters with a colored background. The visual symptoms were constant except for several hours in the evening when there was total resolution after her daily vodka and white wine. There was a history of recurring headaches since the age of 20 occurring about once a week or sometimes more often consistent with migraine without aura, relieved by acetaminophen. Perhaps 10 years ago, she believes that she may have had similar visual symptoms once or twice for a brief time. No other history of visual aura. During the time that she has had the persistent visual symptoms, she has had her usual headaches about once a week, relieved by acetaminophen in about 1 hour. A magnetic resonance imaging (MRI) of the brain and magnetic resonance angiogram (MRA) of the brain and erythrocyte sedimentation rate were normal. Evaluations by her cardiologist, ophthalmologist, and retina specialist were all normal except for age-related macular degeneration. A prior neurologist had started her on divalproex sodium which was discontinued due to nausea. Over the next 4 weeks, the symptoms persisted with only a slight decrease in intensity despite treatment with 60 mg of prednisone daily for 3 days, topiramate 100 mg daily, intravenous valproic acid 500 mg every 8 hours for 2.5 days, 20 mg of intravenous furosemide, and 10 mg of intravenous promethazine. Case 2.—A 25-year-old woman has had recurring headaches since the age of 7. The headaches have increased in frequency, becoming almost daily for the last couple of months, with a bilateral aching with an intensity of 6/10, present most of the time with light and noise sensitivity and occasional nausea. She has been taking no medications for the headaches. Since the age of 7, she rather constantly sees what she describes as television static that is getting worse and more noticeable. She sees tiny air molecules, also described as rain on a window, which are most noticeable if she is looking at the sky or a white background, present in both eyes and with the eyes closed. The symptoms can interfere with reading. There is a past history of attention deficit disorder on amphetamine– dextroamphetamine. Her sister has migraine. Neurological exam was normal. Examination by a From the Baylor College of Medicine, Houston, TX, USA (R.W. Evans); Swedish Pain Center, Seattle, WA, USA (S.K. Aurora).