Migraine with aura during pregnancy.

CLINICAL HISTORY This is a 38-year-old G2 right-handed woman seen at 28 weeks gestation for headaches. At the age of 13, she started having migraines with aura that were frequent for several years and then became less so for many years. During her prior pregnancy 3 years ago, she had 3 migraines with aura. She had no other similar headaches until 2 months ago. She reports 9 episodes with 4 occurring during the prior 2 weeks. Her typical aura involves “squiggles” with scotoma in both eyes for about 30 minutes, no symptoms for 30 minutes, then the same visual symptoms again for 30 minutes followed by a severe bitemporal headache associated with nausea and light sensitivity; her headaches resolve a few hours after taking a butalbital/APAP/caffeine compound and sleeping. She is not aware of any migraine triggers. The last 4 episodes have been different. She develops the same visual aura for 30 minutes, then no symptoms for about 30 minutes, and then the same visual aura but now accompanied by numbness of the fingers of the left hand spreading up the forearm and then to the left forehead, cheek, and lips. The visual and sensory symptoms resolve in about 30 minutes and are then followed by her typical headache. Past medical history is otherwise unremarkable. Her father had migraine. Her blood pressure and neurologic examination were normal. Questions.— How often does migraine with aura become more frequent during the second and third trimesters? Is there any significance to the new sensory symptoms occurring with the visual aura? Is diagnostic testing indicated? Would you recommend migraine preventative medication, and, if so, which one?