PO-09 | When migraine turns severe: a case of aura that lasts too long

Alessandra Fera,¹ Erica Agosto,¹ Giulia Grasso,² Cristina Vassia,² Francesca Feyles,² Carlotta Canavese,³ Sara Racalbuto,² Antonia Versace² | ¹Department of Public Health and Pediatrics, University of Turin; ²Department of Pediatric Emergency, Pediatric Headache Centre, Regina Margherita Children’s Hospital, Turin; ³Department of Child Pathology and Care “Regina Margherita”, SSD Pediatric Neurology, Regina Margherita Children’s Hospital, Turin, Italy

Background: Migraine with aura is common in adolescents and usually recovers after prompt symptomatic treatment. However, status migrainosus (a prolonged, severe migraine attack), often also related to the abuse of symptomatic analgesic, may mimic other acute neurological conditions. Prompt recognition and management are essential.

Case Report: We report the case of a 13-year-old girl previously suffering from migraine with aura. The patient reported an increase in both frequency and intensity of headache episodes, with prolonged duration exceeding 10 days, occurring on a daily basis, accompanied by vomiting and transient neurological symptoms such as dysarthria and paresthesias and showing poor responsiveness to commonly used analgesics. Her typical attacks involved unilateral fronto-temporal pain preceded by visual aura. The patient was admitted to our emergency department with severe headache (NRS 10/10), repeated vomiting, and focal clonic movements of the right limbs. Neurological examination revealed left-sided weakness and neck stiffness. Blood tests showed leukocytosis without signs of systemic inflammation. Brain MRI angiography excluded structural or vascular abnormalities. EEG revealed diffuse cerebral dysfunction, predominantly bilateral anterior and right hemispheric involvement, consistent with migraine status. Intravenous dexamethasone led to clinical and EEG improvement. However, after steroid tapering, symptoms recurred and oral corticosteroids were restarted, achieving clinical stabilization. Psychological evaluation revealed anxiety related to prolonged migraine. The patient was discharged asymptomatic with a steroid tapering schedule, migraine prophylaxis (flunarizine), lifestyle suggestions, and planned follow-up.

Conclusion: This case illustrates refractory status migrainosus in an adolescent, poorly responsive to standard analgesics, presenting with transient neurological deficits and EEG abnormalities but no structural brain damage. Early corticosteroid treatment was critical for recovery. Multidisciplinary management, including psychological support and genetic evaluation, is essential for long-term care and prevention. Furthermore, the excessive use of symptomatic pharmacological agents should be carefully monitored, as it may represent a possible trigger factor in the onset of this neurological disorder.