Teaching case: migraine and pupil dilation.

CASE PRESENTATION History of Present Illness:The patient is a 32-yearold physician with seasonal allergies, depression, and hypothyroidism who presented to the resident neurology clinic for treatment of headaches. At the time of her visit she had a headache.She states that she had her first headache at approximately 5 to 10 years of age.At that time she would get a headache“when the weather was bad and we went to the mall.” These headaches also made her sick to her stomach. She did fine and had no headaches during middle school, high school, and undergraduate college. In her early 20 s, she noticed her first “migraine.” She remembers this day very clearly and said that the weather was cold and rainy and she developed a severe headache over the course of that day.This headache was associated with nausea, photophobia, and phonophobia. These “migraines” came very infrequently in her 20 s, every 1-2 years, and this included vigorous academic training such as during her professional training. At the time of a recent headache she states she was told her right pupil was enlarged.She has subsequently noted this on a few occasions during headache. For the several months prior to her initial visit, she has had headaches every 2 or 3 weeks. Her headaches are also recently associated with vertigo, which comes on at the onset of the headache or slightly after the headache begins. She was using 400 mg of ibuprofen when she has a migraine, which helped some, and pseudephedrine, which helps her sleep. Her headaches last greater than 12 hours and at most 48 hours and seemed to be worsening in severity, lasting longer and harder to abort.She denied any other neurologic symptoms such as diplopia, dysarthria,dysphagia,syncope,or focal weakness.She had no visual changes. She had no other aura, which preceded the headache. A computed tomography (CT) scan of the head was normal. The patient also has considerable neck pain, which is bilateral, left greater than right, and primarily in the upper trapezius and levator scapulae muscles. Triggers for migraines appear to be primarily dropping of barometric pressure and possibly stress. Past Medical History is remarkable for hypothyroidism, depression, endometriosis, seasonal allergies, and asthma, exacerbated by allergies and changes in elevation. Family History: There is no known family history of headache. Her mother is 57 and has fibromyalgia and anxiety. Her father is 63 and has depression. Her sister has some anxiety and allergies. Social History: She works here as a physician. She is single. She denies ethanol (ETOH), smoking, or drug use. Medications on initial visit: