A 57-year-old White woman admitted to the hospital accompanied by her daughter complaining of the severe headache and behavioral changes during the last 4 days. The patient reports of suffering from severe MwtA for more than 20 years. She was diagnosed with an episodic migraine without aura according to the International Headache Society criteria, on the second year of the disease. The patient underwent a head MRI, but by the time of the present admission, she did not have the results. Usually, her migraine attacks are severe with vomiting, phonophobia and lasting period of maximum 72 h, MIDAS grade IV (47 score). She takes zolmitriptan 5 mg together with 2 ml of metoclopramide intramuscular injection to treat a migraine attack, which used to bring a relief. Four days before the admission she complained of having another migraine attack, followed by two time vomiting and phonophobia. The migraine attack onset was quite usual for her, without any preceding provocative factors or head trauma. The headache was described as a unilateral, left-sided, pulsating character, worsening with the physical activity and in the presence of loud sound and bright light, evaluated as 8 scores by VAS. She unsuccessfully tried to treat this attack using her regular medications. The relatives of the patient decided to refer her to the doctor 2 days after the headache onset, when they mentioned the signs of sensory aphasia and personality changes in terms of unusually prolonged headache attack. Upon the evaluation, the patient was hardly reachable for a verbal contact because of the severity of the headache, she was notable to have signs of sensory aphasia and phonophobia, the deep tendon reflexes were symmetrically exaggerated, there were no signs of paresis or other focal neurological deficit. The fundoscopy was not performed. General blood analysis was unremarkable HGB 135 g/l, RBC 4.28 × 1012/l, PLT 192 103/μl, total leukocyte count of 6.7 × 109/l, except for elevated ESR 38 mm/h. The patient underwent also biochemical analysis of the blood which did not reveal any abnormal values (glucose 7 mmol/l, total cholesterol level 225 mg/dl, AST 23 U/L, ALT 21 U/l, creatinine 0.62 mg/dl, total bilirubin 22 mcmol/l). She has no history of family cerebrovascular diseases, no history of any other comorbid diseases. The patient’s daughter denied any consumption of the psychotropic substances by her mother, taking any regular medication, as well as any other medication during the migraine attack, except for zolmitriptan and metoclopramide. A brain MRI scan, performed on Philips Achieva 3.0T, India, was significant for revealing intraparenchymal hemorrhage in the left temporal lobe, with perifocal edema and two subdural hematomas in frontal and temporal regions on the left (Fig. 1).
Computed tomography angiography (CTA), performed on Siemens, Somatom Sensation 16, did not reveal any aneurysmatic dilatations vascular malformations (Fig. 2).
The patient was suspicious for having either primary or secondary neoplastic lesion of the left temporal lobe with consequent hemorrhage in it. She was referred to the neurosurgeon, where she was prescribed to take dexamethasone 4 mg once per day and regular hemorrhagic stroke treatment until getting the control contrast enhancing MRI scan and spectroscopy. She was discharged without any clinical symptoms in 10 days. Control brain MRI scan (Philips Achieva 3.0T), which was performed in 2 weeks (Fig. 3) revealed decrease in size of the intraparenchymal hemorrhage, complete involution of the subdural hematomas. MR spectroscopy did not prove the diagnosis of a neoplasm.
Based on patient’s medical history, the results of clinical, laboratory and neuroimaging studies, the diagnosis of a complicated migraine was made. The patient was prescribed candesartan 4 mg/day with the weekly increase of dosage for 4 mg up to 16 mg/day, with both blood pressure control and migraine prophylaxis aim. On the follow-up visit in 3 weeks, the patient was without any signs of neurological deficit presence, the blood pressure controlled at the level of 110/70 mm/Hg. None of the adverse effects were present. The consent for participation and publication of the study was received from the patient. The study was approved by the local ethics committee.
