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What Causes Severe Headaches?
Question: Hi Doctor:
My daughter is 35 years old and has suffered with severe mirgraine headaches since 9 years old. Has been on numerous medications.She currently takes Toradol. Last week she had trouble waking up in the morning when alarm went off. Which normally she hears it everyday. Her family said they had to call her several times to wake her up. When she did wake up she woke up with a severe headache the worse she has ever had. Does not recall the incident. Went to the er MRI; CT scan came back fine although without contrast.
EEG revealed abnormal indicating paroxismal episodic dysfunction of left cerebral hemisphere, suggestive of seizure disorder. She does have right sided weakness.
My daughter is 35 years old and has suffered with severe mirgraine headaches since 9 years old. Has been on numerous medications.She currently takes Toradol. Last week she had trouble waking up in the morning when alarm went off. Which normally she hears it everyday. Her family said they had to call her several times to wake her up. When she did wake up she woke up with a severe headache the worse she has ever had. Does not recall the incident. Went to the er MRI; CT scan came back fine although without contrast.
EEG revealed abnormal indicating paroxismal episodic dysfunction of left cerebral hemisphere, suggestive of seizure disorder. She does have right sided weakness.
Brief Answer:
Possible sz disorder vs. complicated migraine
Detailed Answer:
Good afternoon. My name is Dr. Dariush Saghafi and I am a neurologist/headache specialist. I understand that your daughter who is 35 years old is being treated with Toradol for her migraine headaches which have been present since age 9. She's been tried on numerous medications. The other day she did not wake up to her alarm which is unusual. When her family was finally able to arouse her to get up she demonstrated a severe headache which was described as the very worst ever along with right sided weakness. You state that imaging studies of the brain were negative but that an EEG showed left hemispheric paroxysmal episodic dysfunction and that the suggestive diagnosis by EEG was that of seizure disorder.
Since you are not asking any specific question I will simply complement the information you've provided by saying that in my opinion I believe the data are consistent with a possible seizure disorder and that her right sided weakness that was witnessed by the family (in the face of negative MRI findings. It would've been nice if there was a suspicion of seizure disorder to go ahead and get a contrasted study as well as fine cuts through the optic chiasm...but unfortuantely, this was not looked at) may have been demonstrative of what is known as a Todd's paralysis. This is where focal weakness either on the right or left side of the body follows a convulsive episode of one of the hemispheres of the brain.
I would be interested (if I were the attending neurologist to define a bit more why only the left hemisphere seems to be involved in the paroxysmal activity since there are several infectious entities that could be thought of in that context...however, we need to keep in mind that MRI did not show any evidence of hemorrhagic activity). If they can define why she has such a focality of disorder then, there may be a solution to the problem.
If you would wish to ask more specific questions about this problem then, I will be happy to answer them for you. If not and if this information has been useful to you would you terribly mind a bit of written feedback describing how well I answered your needs (although I admit that I only guestimated what you might want to ask since there were no specific questions).
A STAR RATING of this question would be very much appreciated and if you would like to contact me in the future with direct queries then, I invite you to write to me at:
bit.ly/drdariushsaghafi
This query required 19 minutes of physician specific time required for review, research, and final draft compilation for envoy.
Wish the best to your sister.
P.S. Interestingly enough I see that you live very close to my birth city of New Brunswick. I was born in Middlesex Memorial which of course now is the XXXXXXX Wood XXXXXXX University Hospital. I don't recall much of the place since we moved when I was a toddler....but there are pictures. Cheers!
Possible sz disorder vs. complicated migraine
Detailed Answer:
Good afternoon. My name is Dr. Dariush Saghafi and I am a neurologist/headache specialist. I understand that your daughter who is 35 years old is being treated with Toradol for her migraine headaches which have been present since age 9. She's been tried on numerous medications. The other day she did not wake up to her alarm which is unusual. When her family was finally able to arouse her to get up she demonstrated a severe headache which was described as the very worst ever along with right sided weakness. You state that imaging studies of the brain were negative but that an EEG showed left hemispheric paroxysmal episodic dysfunction and that the suggestive diagnosis by EEG was that of seizure disorder.
Since you are not asking any specific question I will simply complement the information you've provided by saying that in my opinion I believe the data are consistent with a possible seizure disorder and that her right sided weakness that was witnessed by the family (in the face of negative MRI findings. It would've been nice if there was a suspicion of seizure disorder to go ahead and get a contrasted study as well as fine cuts through the optic chiasm...but unfortuantely, this was not looked at) may have been demonstrative of what is known as a Todd's paralysis. This is where focal weakness either on the right or left side of the body follows a convulsive episode of one of the hemispheres of the brain.
I would be interested (if I were the attending neurologist to define a bit more why only the left hemisphere seems to be involved in the paroxysmal activity since there are several infectious entities that could be thought of in that context...however, we need to keep in mind that MRI did not show any evidence of hemorrhagic activity). If they can define why she has such a focality of disorder then, there may be a solution to the problem.
If you would wish to ask more specific questions about this problem then, I will be happy to answer them for you. If not and if this information has been useful to you would you terribly mind a bit of written feedback describing how well I answered your needs (although I admit that I only guestimated what you might want to ask since there were no specific questions).
A STAR RATING of this question would be very much appreciated and if you would like to contact me in the future with direct queries then, I invite you to write to me at:
bit.ly/drdariushsaghafi
This query required 19 minutes of physician specific time required for review, research, and final draft compilation for envoy.
Wish the best to your sister.
P.S. Interestingly enough I see that you live very close to my birth city of New Brunswick. I was born in Middlesex Memorial which of course now is the XXXXXXX Wood XXXXXXX University Hospital. I don't recall much of the place since we moved when I was a toddler....but there are pictures. Cheers!
Above answer was peer-reviewed by :
Dr. Vinay Bhardwaj
Hi Dr Dariush:
Thank you so much for answering me back. You gave me a lot of information. I am so concerned about my daughter. Her headache feels a bit better than previously. I wonder why they did not do mra or mri/ct scan with contrast. They discharged her from hospital then called her the following day to tell her about the abnormal EEG. Do you think there could be an underlying lesion in the brain or would have the mri picked it up? She is alert and oriented. What in your opinion could have caused the abnormal eeg? She is scheduled for eeg videos for 2-3days. Thank you so much for all of your help.
Thank you so much for answering me back. You gave me a lot of information. I am so concerned about my daughter. Her headache feels a bit better than previously. I wonder why they did not do mra or mri/ct scan with contrast. They discharged her from hospital then called her the following day to tell her about the abnormal EEG. Do you think there could be an underlying lesion in the brain or would have the mri picked it up? She is alert and oriented. What in your opinion could have caused the abnormal eeg? She is scheduled for eeg videos for 2-3days. Thank you so much for all of your help.
Brief Answer:
Glad that headaches are better
Detailed Answer:
The presence of a FOCAL (meaning 1 sided) EEG finding is always concerning for a specific pathology within the left hemisphere that is responsible such as a mass, AVM, or possible infectious entity. You didn't mention an entity called PLEDS which is the sine qua non for a Herpes Encephalits. I think this should always be THOUGHT about but the absence of any brain blood kind of makes that entity less likely. The best reason to do a contrasted study in someone her age would be precisely to look for a very small mass lesion that could otherwise be missed or also to look for something called Mesial Temporal Sclerosis (MTS). Again, a bit less likely since while MTS can come about as a result of a focal enlargement or sclerois of just ONE temporal lobe pole or region...the EEG findings are generally more disbursed and diffuse instead of so hemispheric specific. The MRA with contrast would not be very helpful but the MRI with contrast may be helpful and in my opinion should be completed for a matter of completeness. I'm not exactly clear on the video monitoring necessity since that's several days in the hospital. They could've also set up ambulatory EEG so she could be at home and not in the hospital. Not sure the video component is going to add that much to the diagnosis but that is much better the call of the neurologist following the patient sinice he/she has physically seen her.
If you would wish to ask more specific questions about this problem then, I will be happy to answer them for you. If not and if this information has been sufficiently useful to you would you mind some written feedback?
A STAR RATING of this question would be very much appreciated & if you'd like to contact me in the future with direct queries then, please write to me at:
bit.ly/drdariushsaghafi
This query required 13 minutes of physician specific time for review, research, and final draft compilation for envoy.
Glad that headaches are better
Detailed Answer:
The presence of a FOCAL (meaning 1 sided) EEG finding is always concerning for a specific pathology within the left hemisphere that is responsible such as a mass, AVM, or possible infectious entity. You didn't mention an entity called PLEDS which is the sine qua non for a Herpes Encephalits. I think this should always be THOUGHT about but the absence of any brain blood kind of makes that entity less likely. The best reason to do a contrasted study in someone her age would be precisely to look for a very small mass lesion that could otherwise be missed or also to look for something called Mesial Temporal Sclerosis (MTS). Again, a bit less likely since while MTS can come about as a result of a focal enlargement or sclerois of just ONE temporal lobe pole or region...the EEG findings are generally more disbursed and diffuse instead of so hemispheric specific. The MRA with contrast would not be very helpful but the MRI with contrast may be helpful and in my opinion should be completed for a matter of completeness. I'm not exactly clear on the video monitoring necessity since that's several days in the hospital. They could've also set up ambulatory EEG so she could be at home and not in the hospital. Not sure the video component is going to add that much to the diagnosis but that is much better the call of the neurologist following the patient sinice he/she has physically seen her.
If you would wish to ask more specific questions about this problem then, I will be happy to answer them for you. If not and if this information has been sufficiently useful to you would you mind some written feedback?
A STAR RATING of this question would be very much appreciated & if you'd like to contact me in the future with direct queries then, please write to me at:
bit.ly/drdariushsaghafi
This query required 13 minutes of physician specific time for review, research, and final draft compilation for envoy.
Above answer was peer-reviewed by :
Dr. Bhagyalaxmi Nalaparaju
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