Migraine with Visual Aura: A Clinical Manifestation of Cerebrovascular Disorders in Childhood

Abstract

Cerebral vascular pathology mostly gets manifest in early adulthood. Bleeding, epileptic seizure, and focal neurologic deficits are the most common clinical presentations leading to the diagnosis. We present two children with migraine headache and visual aura as first symptoms. Case 1: A 7-year-old girl suffers from classical clinical symptoms of a migraine with visual aura. Cranial magnetic resonance imaging (MRI) scan revealed a large arteriovenous (AV) malformation in the right occipital lobe without signs of bleeding. As there were no epileptic seizures and just minimal restriction in the visual field, a watchful-waiting approach was preferred. In the 7 year follow-up, the clinical manifestation remained stable with variable amount of migraine attacks. Though the follow-up MRI showed an unchanged overall size of the AV malformation, the venous drainage and shunt volume raised and thereby the risk of bleeding. The possible and also risky therapeutic options versus further watchful-waiting approach are actually discussed with the family. Case 2: A 10-year-old boy suffers, since he is 7 years old, from left-sided temporal-parietal headache with visual aura and vertigo. As the frequency of the attacks significant rose (2-4 attacks/week), the boy sought medical advice. Cranial MRI and the following angiography showed a giant intracranial aneurysm of the cavernous part of the internal carotid (two aneurysm “pockets” with 1.5 cm diameter each) with local compression especially of the left optic nerve. Hints for an aneurysm associated illness or familiar burden were not found. After a positive occlusion test, a combined neuroradiological and neurosurgical approach with coiling and clipping of the left internal carotid was realized without complications. Conclusion: In children suffering from migraine with visual aura, which presents less often than migraine without aura, a cranial MRI should be considered, as it may be the first clinical sign of rare cerebrovascular disorders.