Silent Migraine with Visual Aura in Young Adult with Multiple Comorbidities
Case at a Glance
A 22-year-old female with hypermobile Ehlers-Danlos syndrome (hEDS), postural orthostatic tachycardia syndrome (POTS), and irritable bowel syndrome presents with recurrent episodes of visual aura without subsequent headache, concerning for silent migraine. Patient has family history of Chiari malformation and recent stroke in grandfather.
Patient's Story
The patient experienced two distinct episodes of visual disturbances. The first occurred during finals week in December during high stress, presenting as 'evil sparkles' on the right side of vision without subsequent headache. The second episode occurred while gaming, described as feeling like a flashlight had been shined in her left eye with persistent sparkly, glitch-like visual phenomena. In both instances, the visual symptoms resolved without developing into a full migraine headache. The patient's partner, who has migraine experience, recognized the symptoms and provided abortive medication (Excedrin) during both episodes.
Initial Assessment
Patient presents with recurrent visual aura episodes consistent with migraine aura without headache (silent migraine). Current medications include lamotrigine 200mg daily for mood stabilization and combined oral contraceptive pills. Patient reports moderate alcohol consumption (1-2 shots, 4 times weekly) and denies tobacco or illicit drug use. Positive family history includes brother with Chiari malformation and migraines, and grandfather with recent stroke.
The Diagnostic Journey
Initial concern arose due to the unusual presentation of isolated visual aura without headache pain. Given the patient's complex medical history including connective tissue disorder, autonomic dysfunction, and current use of hormonal contraception, comprehensive evaluation was warranted. Family history of structural brain abnormalities (Chiari malformation) and recent stroke in grandfather heightened clinical suspicion for underlying vascular or structural causes.
Final Diagnosis
Silent migraine with visual aura. The recurrent nature of symptoms, characteristic visual phenomena, and response to migraine abortive therapy supported this diagnosis. However, the combination of migraine with aura and hormonal contraceptive use presents increased thromboembolic risk requiring medication adjustment.
Treatment Plan
Immediate discontinuation of combined oral contraceptive pills due to contraindication with migraine with aura (increased stroke risk). Transition to progestin-only contraceptive method or non-hormonal alternatives. Migraine prophylaxis consideration given recurrent episodes. Patient counseled on migraine triggers including stress and alcohol consumption. Neuroimaging may be considered given family history of Chiari malformation.
Outcome and Follow-up
Patient showed good understanding of the relationship between hormonal contraceptives and migraine with aura. Scheduled for contraceptive counseling and potential neurology referral for migraine management. Regular monitoring planned to assess frequency of episodes and effectiveness of preventive strategies. Patient advised to maintain migraine diary and seek immediate care for any change in symptom pattern or development of neurological deficits.