A 22 year-old boy presented for evaluation of a year history of periodic visual disturbance

Introduction

Headache-free migraine is a condition with no headache, but is associated with other migraine symptoms, such as visual problems, nausea, vomiting, constipation, or diarrhea. Migraine is described as a familial disorder characterized by recurrent headaches that are variable in intensity, frequency, and duration. Attacks are usually unilateral but can also be bilateral and accompanied by photophobia, phonophobia, nausea, and vomiting. Some migraines are preceded by, or are associated with, neurological and mood disturbances. All of the above characteristics, however, are not necessarily present in each attack, or in each patient.

Case Report

A 22 year-old boy was admitted to our family medicine clinic with a one-year history of periodic visual disturbance. He had accompanying dizziness problem. The first attack of visual disturbance occurred one year ago while he was studying for an exam.

It started as a bilateral, small, central circular distortion, and then enlarged until it grew out of the patient's visual field leading to temporary blindness over a 20-minute period. He visited an ophtalmologist.

Tests for vasculitis and coagulopathy (complete blood count, partial thromboplastin time, erythrocyte sedimentation rate, rheumatoid factor, antinuclear antibody titer, homocysteine level and serum protein electrophoresis) were normal.

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Visual field test, corneal tomography, cranial MRI (Magnetic resonance imaging) and noninvasive carotid and retinal ultrasound Doppler and echocardiography were performed in order to rule out cerebral, vascular and cardiac causes. All results were in normal range and the etiology of his complaints could not be explained and this caused patient dissatisfaction. He did not have any problems until three months ago. During the last three months he had four attacks. All episodes were similar in nature, with an expanding scintillating scotoma and without subsequent headache. Except for the last one, all attacks occurred while he was studying. There was no history of paresthesia, olfactory or auditory disturbance, nausea, vomiting, or preceding headache. He wore eyeglasses for myopia. He had no medication, no illicit drug use, and was otherwise healthy except for a history of irritable bowel syndrome. On the other hand, there was a family history of migraines both in his mother and his aunt. Physical and neurological examinations were within normal limits. He was anxious about his health and future career. He had fear of blindness. His anxiety increased during the last year. Our diagnosis was migraine aura without headache. Since his episodes of scotoma occurred only sporadically and seemed to be associated with anxiety, we prescribed him a SSRI (Selective Serotonin Reuptake Inhibitor). He was followed up for one year and was encouraged to keep a diary of visual phenomena, paying particular attention to activity, diet, and associated symptoms. During the follow-up he did not have any recurrence of attacks.

Discussion

The terms headache-free migraine or migraine equivalents have been replaced within the Classification and Diagnostic Criteria for Headache Disorders, Cranial Neuralgias and Facial Pain by the Headache Classification Committee of the International Headache Society (1). These previous designations have been replaced by the term migraine aura without headache, which describes migrainous events exclusively manifested by one of the neurological disturbances that usually precede or accompany the headache of classical migraine (2).

While headache-free migraine would fall into the category of migraine aura without headache, episodes of migraine aura without headache can occur in individuals with a history of classic migraine. Approximately 20% of migraineurs may experience acephalgic attacks of migraine at one time or another (3).

In the absence of the classic headache, the patient's predominant visual phenomenon must be well described and chronicled in order to avoid diagnostic errors. Thus, when a patient is unable to provide an accurate accounting, the clinician is compelled to search for other causes of photopsia: environmental agents, or specific abnormalities of the eye, including problems with the cornea, lens, vitreous body, and retina, or abnormalities of the brain or cardiovascular system. All differential diagnostic tests were performed in our patient and were in normal ranges.

The diagnosis of migraine aura without headache should be made only after the possibility of organic disease has been systematically excluded through a detailed patient history and examination. The diagnosis of migraine aura without headache can be entertained if the patient has the major migraine characteristics, including migration of scintillating scotoma, recurrences of similar episodes of 15 to 30 minutes' duration, a history of similar spells with headache, an eventually benign course, and a normal physical, ophthalmologic, and neurological examination (1).

Patients require information for their health problems and its treatment and they desire patient-centered communication. Learning about patients' expectations can be educational for care providers, because it helps them to clarify their own expectations and to set priorities for learning and improvement (4).

Time and the opportunity for continuing care are very powerful diagnostic instruments in the hands of family physicians (FPs) (5). A doctor cannot overcome undifferentiated and unorganized health problems unless he follows-up his patients for a long time. That was the reason for our patient being encouraged to keep a diary of visual phenomena, paying particular attention to activity, diet, and associated symptoms. Family physicians are frequently consulted by patients in the early and undifferentiated stages of disease. One of the reasons of undifferentiating is self-limiting health problems like our case. Uncertainty is a part of daily life in family practice.

As family physicians, we use as diagnostic methods “less technology” but “more time” than the other specialists. We should define the patients' expectations to achieve patient satisfaction. We have more chance than the other specialists to manage undifferentiated problems.

Acknowledgement

We thank Assoc. Prof. Dr. Meltem Demirkiran from Department of Neurology for the critical reading of this case report.

References

1. Headache Classification Committee of the IHS. Classification and diagnostic criteria for headache disorders, cranial neuralgias and facial pain. Cephalalgia 1988;8:1-96.

2. Pedersen DM, Wilson WM, White GL Jr, Murdock RT, Digre KB. Migraine aura without headache. J Fam Pract 1991;32:520-23.

3. Hupp SL, Kline LB, Corbet JJ. Visual disturbance of migraine. Surv Ophthalmol 1989;33:221-36.

4. Wensing M. Patients' expectations of treatment. In: Jones R, Britten N, Culpepper L, Gass D, Grol R, Mant D, Silagy C. (Eds). Oxford Text Book of Primary Medical Care. 1st ed. New York, Oxford University Press Inc 2005;1:122-26.

5. Wonca Europe 2002 report. The European Definition of General Practice/Family Medicine.

CORRESPONDING AUTHOR

Assoc. Prof. Dr. Esra Saatçı

Department of Family Medicine, Faculty of Medicine, Cukurova University,

Balcali, 01330 Adana, Turkey.

Phone: +90-322-338 6855

Fax: +90-322-338 65 72

E-mail: esaatci@cu.edu.tr

Submitted date: 16.04.2007

Accepted date: 09.06.2007