*

Aaron McCoy, MD, PGY3

* Otherwise healthy 14 year old that presented to the PCMC ED after an

event of acute HA, right facial numbness, difficulty word finding and right hand paresthesia. * She participated in AAU basketball practice around 06:30 without any difficulty. She then went to her high school classes. Around 08:00, she noted some flashing lights in her eyes along with some blurred vision. This lasted a few minutes and then resolved. * A few hours later that morning while on a field trip with her class, she developed the worst headache she had ever had (8-9/10 pain, in her temporal areas, no throbbing) and also noted some right facial numbness like when you go to the dentist, difficulty with word finding (she knew what she wanted to say, she just couldnt say it), and right hand numbness and tingling. * She denied any photophobia or phonophobia. This lasted a few minutes and then self-resolved. * With these symptoms, her parents were called. They immediately brought her via private vehicle to PCH. On arrival to PCH, her only complaint was a 4-5/10 headache.

* PMH: None * FH: No clotting or bleeding disorders in the family,

no history of early strokes, dad with a history of a migraine years ago, no other family history of migraines or chronic headaches * SH: Lives in Utah, she is in high school and is doing well, denies any increased stress in her life at this point, denies any drug or alcohol use * Medications: None regular, received Ibuprofen on way to ED, no OCPs * Allergies: None

* Vitals: T 36.0 RR 14 HR 60 BP 110/80 Sats 96% * General: No acute distress, appropriately concerned over her prior *

*
* * * * * *

symptoms, well developed and nourished Neurological exam: Cranial nerve testing normal, strength 5/5 in all 4 extremities, sensation to touch normal in all 4 extremities, no dysdiadochokinesia, Rhomberg testing normal Extremities: No edema in any extremity, no tenderness or swelling in LEs bilaterally HEENT: TMs clear, pharynx clear, no LAD CV: S1, S2, no MRGs Resp: CTAB, no increased work of breathing or distress Abd: Soft, non-tender, non-distended or organomegally Skin: No rash or lesion GU: Deferred

* Started on Stroke Protocol- labs, Q15 neuro checks,

1.5x maintence fluids, neuroimaging. * Blood Glucose 92 * iCal 1.22 * Fibrinogen 315 * PTT 34 * PT/INR 14.0/1.1 * Serum Drug Screen WNL * CBC WBC 7.3, HCT 39.3, PLTS 221, Neut 88%, Lymp 7% * CMP WNL

* MRI Brain w/o contrast: No evidence of acute

ischemic event or acute intracranial process

* MRA Brain w/o contrast: Normal. Bilateral

ICAs, MCAs, ACAs, vertebrobasilar system, bilateral PCAs are normal.

bilateral common carotid arteries and bifurcations, cervical ICAs and vertebral arteries.

* MRA Neck w/o contrast: Normal aortic arch,

Classified as:

* Migraine without aura (most

common)

* Migraine with aura * Childhood periodic

*
Migraine- Recurrent or episodic attacks of head pain plus a variety of symptoms separated by symptoms- free intervals.

syndromes that commonly are pre-cursors: abdominal migraine, benign paroxysmal vertigo, cyclical vomiting

* Basilar-type * Familial Hemiplegic

Migraine

* H&P (thorough neurological exam) * Routine neuro imaging is not indicated in

children with recurrent HAs and a normal neurological exam but can be considered in a child with neurological dysfunction, change in HA, or recent onset of severe headache

* Routine EEG is not recommended as a part of

the HA evaluation

* Migraine aura represents transient, focal

somatosensory phenomena like the classic scotoma or visual distortion/illusions (balloons, colors, rainbows) but can consist of hemiparesis, vertigo, or aphasia. depolarization and accompanying regional hypoperfusion.

* Thought to be caused by regional neuronal

* Basilar-type: Episodes of dizziness, vertigo,

visual disturbance, ataxia, dysarthria, tinnitus, hypacusia, paresthesia, diplopia, decreased consciousness and headache may be occipital (most migraines are not). * Familial Hemiplegic Migraine: Autosomal dominant, calcium channel gene mutation, HA heralded by strokelike sx. Focal neuro sx precede HA by 30-60 min. Side of HA is contralateral to focal neuro sx.