Hyperperfusion With Vasogenic Leakage By FMRI In Migraine With Prolonged Aura.

The pathogenesis of migraine is thought to follow a defined temporal and spatial sequence of events. Brainstem activation and stimulation of meningeal blood vessels by trigeminal sensory nerves causes release of vasoactive substances and vasodilation of intracranial extracerebral blood vessels. Further irritation of the peripheral trigeminal sensory nerves establishes a cyclical pathway and persistent headache.1 Here, we describe a case of prolonged aura during migraine with neuroimaging that demonstrates increased perfusion and leakage of contrast into the subarachnoid space. A 66-year-old white woman had a long-standing history of migraine with onset at age 9 years and was being treated with verapamil. Family history was notable for migraine in both the patient’s daughter and mother. Prior evaluation including MRI of the head was unremarkable. Her typical episodes lasted 1 day and were associated with visual scotoma followed by transient expressive aphasia, but no weakness. One week before the current hospitalization, she stopped taking verapamil and subsequently presented with her typical migraine symptoms, which then progressed to include nausea, vomiting, and global aphasia over the ensuing days. Given the extended duration of her headache, she was taken to the emergency department where her workup included an unremarkable head CT and lumbar puncture, but also fever and leukocyte esterase positive urinalysis. She was administered meperidine and hydroxyzine with ceftriaxone. She was discharged with a diagnosis of migraine, exacerbated by a urinary tract …