1. A 7-year-old girl presents to the urgent care from her school where she was seen wondering around the playground and appeared confused. She also complained of spinning sensation of the room, and new double vision. As per the teacher, over the last 30 minutes, she appeared to be clumsy, and her speech was difficult to understand. On presentation, she is now complaining of headache which is holocephalic and requesting the examining lights to be turned off and lying still in bed. When the mother arrives, she states that the child has had at least 2 similar episodes in the past. Mother describes that the child is generally is back to baseline after an extended nap. Which of the following is the most likely diagnosis?
2. A 15-year-old boy comes to an ophthalmologist for evaluation of recurrent (at least 4 episodes in last 6 months) self-resolving visual symptoms. He describes sudden onset of blind spots whose edges look wavy and alternates from dark to light or vice versa, described as if viewing from a kaleidoscope, that affects only one of his eyes at a time. It appears to be gradually spreading over 5 minutes and last for about 30-60 minutes. On few occasions, it has been followed with a headache that is frontotemporal, 6/10 in intensity, at times associated with the nausea and he prefers to sleep in a dark quiet room and often the symptoms subsides when he gets up from a nap. He denies any other symptoms. A detailed ophthalmological evaluation reveals no deficits in near or far vision, peripheral vision testing shows no scotoma, and optical coherence tomography (OCT) is normal, with the optic nerve and retina appearing healthy. He has a strong family history of migraine with aura on maternal side of the family. Based on this information, what is the most likely diagnosis?
3. A 13-year-old girl has a 2-year history of intermittent headaches. These headaches are characterized by onset with a visual aura of flashing lights, followed in 10 minutes by a severe throbbing headache, that she rates as a 9 out of 10 on a visual analog scale. She has nausea, vomiting and photophobia with the headaches and needs to sleep in order to resolve these headaches. They usually last for several hours. Recently there has been an increase in the frequency of her headaches and they are about 2-3/week causing school absence. She has a BMI of 17, struggles with sleep and recently has been having some low mood due to being in pain and missing school. With her daily nausea, she has decreased appetite and lost few pounds in last 3-4 months. During an acute attack she would take Tylenol and sometime Naproxen combined with Zofran, but it doesn’t help always. Which of the following should be next best choice for her acute pain management?
Do you think she needs to be on a prophylactic medication? If yes, which of the following would be your first choice:
4. A 17-year-old boy presents to your clinic for follow-up regarding his migraines. He has a long-standing history of migraines without aura, with a strong family history of migraines on his mother's side. Approximately five years ago, his migraines occurred once a month, but over the past year, their frequency has increased to 2-3 times per week. During his last visit, you emphasized lifestyle modifications, including sleep hygiene, stress relaxation, and hydration, which he has diligently followed. Despite these efforts, he continues to experience headaches and is inquiring about non-pharmaceutical approaches. He is concerned about the side effects of prescription medications and prefers supplements or devices. What would be a reasonable option to consider for trial in this young gentleman? (Multiple options may be correct.)
