A 27-year-old woman has had “migraine” headaches for several years. She recently developed episodes of “flashing lights off to the right” that affect her peripheral vision. Her automated perimetry is shown below. The next step would be:
discontinue oral contraceptives
Answer: A) Cerebral MRI
Explanation: The perimetry images show a partial right homonymous hemianopsia. Although migraine can cause persistent visual field deficit, it is unusual. Cerebral arteriovenous malformations and tumors can mimic migraine and cause visual field loss. Therefore, neuroimaging is essential. Oral contraceptives can exacerbate migraine, and sumatriptan (Imitrex) is an effective form of migraine treatment in about 80% of patients. Both of these measures would apply only if the appropriate evaluation was normal. A tangent screen can be used if malingering is suspected.