Cluster and other nonmigraine primary headaches with aura.

Migraine aura is characterized by focal neurologic features of visual and/or sensory and/or speech disturbance, which precede or accompany a headache attack developing gradually over 5 to 20 minutes with a duration of no longer than 1 hour. In a sample of 163 migraineurs with aura from the general population, visual symptoms were most frequent (99%), followed by sensory (31%), aphasic (18%), and motor (6%) symptoms followed by headache in 93%. The visual presentation of a migraine aura is varied and scintillating zigzags moving laterally in different quadrants of vision as well as objects surrounded by luminous angles, such as fortifications, hazy spots, shining and flickering star-shaped figures are usually described by patients. Cluster headache (CH) is a primary headache well defined in the International Classification of Headache Disorders, second edition, with high specific and sensitive criteria which do not include the presence of aura. The following 2 patients meet episodic CH criteria but also have visual auras. CLINICAL HISTORIES Case One.—A 51-year-old man with a history of episodic cluster headache attacks since the age of 33 years occurring nearly every 2 years with a duration of 6 weeks. The last 4 cluster periods responded well to the use of prednisone for transitional therapy, verapamil for prevention, and injectable sumatriptan (3 mg) for acute attacks. Since the onset of the current cluster period 14 days prior to presentation, the patient developed black-and-white checkerboard visual hallucinations and/or black-and-white flashing lights, lasting for approximately 20 minutes preceding the most severe attacks. Aura only occurred before a headache in 11 out of 14 days during this time when he experienced a mean frequency of 2 attacks per day. There was no personal or family history of migraine, cluster headache, or visual disturbances. The patient was a heavy smoker (30-40 cigarettes/day, but had been smoking less than 20 cigarettes/day for nearly 1 year). Alcohol ingestion was infrequent and had triggered cluster attacks in the past. Ophthalmologic and neurologic examinations as well as brain and orbital magnetic resonance imaging scans were normal. Case Two.—A 46-year-old man with episodic cluster headaches since the age of 29 years presented with shooting black-and-white flashing lights lasting approximately 15 minutes (occurring rarely up to as many as 30 minutes) preceding headache attacks Cases submitted by: Abouch V. Krymchantowski, MD, MSc, PhD, FAHS, Headache Center of Rio, Rua Siqueira Campos, 43/1002 Copacabana, Rio de Janeiro Brazil.