SHARE @ Advocate Health - Midwest - Scientific Day: Migraines Are a Pain - Especially When They Are Not Migraines: A Case of an Atypical Headache
 

Affiliations

Advocate Children's Hospital

Abstract

Introduction/Background:

Rotational Vertebral Artery Syndrome, or Bow Hunter’s Syndrome, is characterized by vertebral artery occlusion or stenosis due to compression from cervical vertebrae or bony abnormalities, leading to ischemia with head movement. Its prevalence is not well documented, but it is most common in the fifth to seventh decades of life, more common in men, and the left vertebral artery is more often affected. The gold standard of diagnosis is cerebral angiogram.

Description:

A 9-year-old male with a recent diagnosis of abdominal migraines with aura presented with acute right-sided numbness, weakness, and unsteady gait. There was no recent illness or trauma. The patient had three recent ED visits for headache, blurry vision, dizziness, and right-sided facial and upper extremity numbness, typically resolving within 15 minutes. Workups, including MRI/MRV/MRA, only revealed a Chiari I malformation. However, this episode had been ongoing for several hours. In the ED, vitals were normal. Mental status was appropriate, and strength was normal. However, he had mild pronator drift of the right arm and leg, dysmetria on the right finger-to-nose test, right facial droop, and intermittent unsteadiness, prompting a stroke code. MRI showed a nonhemorrhagic left thalamic infarct. MRA head and neck were unremarkable. Basic labs, cardiac, and coagulation tests were normal. Hematology and neurology teams were consulted, and daily aspirin was started. On day three of admission, he had a new right leg weakness that lasted 10 minutes. Given the brief intermittent nature of his symptoms, it raised concern for TIAs. A cerebral angiogram was obtained and showed an irregularity in the distal V2/proximal V3 of the left vertebral artery, with focal stenosis exacerbated by head movement, confirming Bow Hunter’s Syndrome.

Discussion:

Both migraines and strokes can present suddenly. In patients with a history of migraines, any sudden, intense symptoms should raise concern for serious underlying conditions. Symptoms of stroke exacerbated by head movement can be a significant clue for Bow Hunter’s Syndrome. In this case, the family recalled an episode when the patient developed symptoms while looking down and kicking a ball, prompting consideration of head/neck positioning as a trigger. Clinicians should maintain a high index of suspicion for structural or vascular abnormalities in cases with recurrent or progressive features.

Presentation Notes

Presented at Scientific Day; May 21, 2025; Park Ridge, IL.

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Poster


 

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May 21st, 11:41 AM May 21st, 1:15 PM

Migraines Are a Pain - Especially When They Are Not Migraines: A Case of an Atypical Headache

Introduction/Background:

Rotational Vertebral Artery Syndrome, or Bow Hunter’s Syndrome, is characterized by vertebral artery occlusion or stenosis due to compression from cervical vertebrae or bony abnormalities, leading to ischemia with head movement. Its prevalence is not well documented, but it is most common in the fifth to seventh decades of life, more common in men, and the left vertebral artery is more often affected. The gold standard of diagnosis is cerebral angiogram.

Description:

A 9-year-old male with a recent diagnosis of abdominal migraines with aura presented with acute right-sided numbness, weakness, and unsteady gait. There was no recent illness or trauma. The patient had three recent ED visits for headache, blurry vision, dizziness, and right-sided facial and upper extremity numbness, typically resolving within 15 minutes. Workups, including MRI/MRV/MRA, only revealed a Chiari I malformation. However, this episode had been ongoing for several hours. In the ED, vitals were normal. Mental status was appropriate, and strength was normal. However, he had mild pronator drift of the right arm and leg, dysmetria on the right finger-to-nose test, right facial droop, and intermittent unsteadiness, prompting a stroke code. MRI showed a nonhemorrhagic left thalamic infarct. MRA head and neck were unremarkable. Basic labs, cardiac, and coagulation tests were normal. Hematology and neurology teams were consulted, and daily aspirin was started. On day three of admission, he had a new right leg weakness that lasted 10 minutes. Given the brief intermittent nature of his symptoms, it raised concern for TIAs. A cerebral angiogram was obtained and showed an irregularity in the distal V2/proximal V3 of the left vertebral artery, with focal stenosis exacerbated by head movement, confirming Bow Hunter’s Syndrome.

Discussion:

Both migraines and strokes can present suddenly. In patients with a history of migraines, any sudden, intense symptoms should raise concern for serious underlying conditions. Symptoms of stroke exacerbated by head movement can be a significant clue for Bow Hunter’s Syndrome. In this case, the family recalled an episode when the patient developed symptoms while looking down and kicking a ball, prompting consideration of head/neck positioning as a trigger. Clinicians should maintain a high index of suspicion for structural or vascular abnormalities in cases with recurrent or progressive features.

 

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