PearlsOy-sters: Hemicrania epileptica: Unfolding the mystery of an unremitting migraine

A 38-year-old woman presented with a right-sided throbbing headache associated with visual symptoms, nausea, vomiting, photophobia, and phonophobia. She had experienced migraines since her teenage years characterized by monthly unilateral headache associated with nausea and photophobia. The current headache had started with symptoms she recognized as her regular monthly migraine, but it had uncharacteristically persisted for 3 days. She also described a persistent aura of “pixelated 3-dimensional objects” and “colored pinwheels,” which she had not experienced with her previous headaches. Two days into the headache, she had developed a defect in her left visual field and had narrowly missed hitting a tree on that side while driving. At the time of presentation to us, she had already undergone a head CT, which was reported normal, and she was prescribed prednisone, sumatriptan, and oxycodone for management of status migrainosus, without benefit.