A patient phoned me from her workplace last week in a good deal of distress. She had suddenly noticed a large part of her visual field was lost, felt nauseous and giddy, and of most concern to her of all, had lost the feeling in one cheek and within her mouth on the same side.
She had recently undergone heart surgery but had no prior medical history of note, nor had she had any of these symptoms before. What are your first thoughts?
If I was to tell you that this was my 20-year-old stepdaughter who had recently undergone correction of a persistent ductus arteriosus under local anaesthetic, was physically fighting fit but under some work stress, would knowing this now sway your initial thoughts?
It did mine and, assuming a likely first migraine with severe aura, I advised she rested somewhere quiet while the physical symptoms subsided and suggested the likelihood of a headache arriving (though this is not always the case as I know). Reassurance and monitoring of future incident was the order of the day and, if the migraines recur, then a physical assessment would be a good idea, now with the possible future option of antibody treatment as we saw in this week’s press.
Migraine is one of those terms which euphemise a battery of sometimes disturbing symptoms with a range of underlying associations which may be significant (nicely represented at www.picturingmedicine.com/differentials).
As visit three approaches in the pre-reg stage one assessments, I am bombarded by emails saying ‘I have yet to see anyone with symptoms of neurological significance’. Knowing that this suggests they have not seen any brain tumours or pupil anomalies yet, I always respond by asking if any of their patients have had a headache.
GPs often advise their headache patients to have an eye test and ruling out the long list of associated ocular and ophthalmic causes is one of our more useful functions.