A 28-year-old Pakistani male presented to the emergency department (ED) complaining of a severe headache. The headache had started 7 days prior to presentation and was localized to the left side of the head with no radiation. The pain was pulsatile and throbbing in nature. The patient rated the pain 9/10 on the visual analog scale. His headache was associated with unilateral photophobia and denied any visual impairment. There were no other associated symptoms and no focal neurological abnormality. The patient had a long-standing history of migraines that started around 2 years ago, experiencing an episode once every 2 weeks. Usually, those episodes subsided with paracetamol and Ibuprofen; on the rare occasion, the patient has had to present to the ED for further management.
Along with his migraine, our patient developed cutaneous markings (Figs. 1 and 2). There were multiple, 1–2-cm non-blanching linear erythematous lesions that appeared on his forehead and disappeared a few days after the headache subsided (Fig. 3). These markings, first appeared in 2014, then reappeared in April 2017 and had been reoccurring with each migraine attack until he visited our ED. The patient correlated the severity of the pain with the size and number of markings. He reported that as his pain increased, the marks would get more intense in color, they started off as red but then eventually would turn blue/black resembling a bruise.
The patient’s past medical history was only significant for dyslipidemia, for which he was on a statin. Of note, the patient has a positive family history for migraines, but denies any migraine-associated cutaneous manifestation in the family. On presentation to the emergency department, the patient vitals were as follows: temperature 36.8 °C, a pulse rate of 118 bpm, a respiratory rate of 18 bpm, and a blood pressure of 148/91 mmHg. On examination, he was alert, oriented to time and place. On further examination, his chest and lungs were clear and he had no focal neurological deficits. His pupils were reactive and his GCS was 15. His forehead showed multiple 1–2-cm erythematous markings that were purple in color and non-tender (as shown in pictures 1 and 2 below). We put the patient on an oxygen mask and gave him 20 mg of metoclopramide IM. The patient was then kept in a dark room to rest, and within 30 min, the patients pain decreased from a severity of 9/10 to a 4/10. Laboratory investigations were not sent in this visit as the patient felt significantly better and had had prior workup done, including an MRI, which were all unremarkable. Although the patient’s pain had significantly improved, the markings were the same. They remained the same size and shape upon discharge. The patient was advised to follow up with a neurologist for further management. When the patient was then later contacted, the markings had disappeared on their own a few days later (Fig. 3).
Differential diagnosis
Our top differential diagnosis was migraines, as the patient’s history was classic of migraines. But we also thought about the possibility of a brain tumor, tension headaches, cluster headaches, and even possibly a vascular disorder. Acute headache causes were ruled out due to the patient’s history of frequent similar episodes of headaches. As the patient has been fully worked up, we ruled out most pathologies including a brain tumor as the MRI was reported normal.
Clinical diagnosis
The clinical diagnosis was migraines with cutaneous manifestations.
