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A 56-year-old man was referred to the neurology service by his general practitioner for further management of his migraine. His symptoms had begun 6 years earlier with a fairly sudden onset headache on waking with associated nausea, vomiting, photophobia and neck stiffness. He was admitted to hospital under the general internal physicians; a CT brain scan was normal. He declined a lumbar puncture. He improved over 3 days and was discharged with a presumed diagnosis of viral meningitis. However, shortly afterwards he began to experience stereotyped headaches, which continued over the ensuing 6 years, about three attacks per week, with up to 2 weeks between attacks. He described the attacks as beginning with ‘lights floating’ in front of his eyes; he couldn't clearly recall if this was monocular or not. He also volunteered a description of ‘white patches floating in front of my vision’. These progressed in intensity over 20 min and then improved, always within an hour. This was then consistently followed by an evolving, throbbing headache, generally focused retro-orbitally on the left, frequently extending posteriorly to the vertex and occiput and also on occasion involving the right side. It would worsen over around 30 min to a severe throbbing pain during which he would lie or sit still. There was associated profound nausea, frequently with vomiting, photophobia and phonophobia. Typical headache duration was around 4 h, with a maximum of 7 h. The only triggers he recognised were coitus, when he would get an attack shortly after orgasm, and ‘artificial light’. There were no additional features, in particular any red eye, tearing, rhinorrhoea or nasal stuffiness. Between these attacks he was entirely headache free, with no systemic, neurological or visual symptoms. There was a background of …
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