Images From Headache Migraine-Like Headache With Autonomic Symptoms in Midbrain Malformation Jay G. Capone, MD; Valentina Simioni, MD; Maria R. Tola, MD We report a case of midbrain malformation characterized by right deviation of the medulla oblongata associated with elongation and ectasia of the basilar and left vertebral arteries in a patient with a long history of migraine-like headache with autonomic symptoms. Key words: midbrain malformation, migraine, autonomic Abbreviations: MRI magnetic resonance imaging, NSAIDs non-steroidal anti-inflammatory drugs, TACs trigeminal autonomic cephalalgias (Headache 2013;••:••-••) A 69-year-old female presented with exacerba- tion of a longstanding headache disorder. Since ado- lescence, the patient had experienced recurrent, left side-locked headache characterized by throbbing, oppressive, retro-orbital, and temporal pain associ- ated with photophobia, phonophobia, nausea, and, rarely, vomiting. During attacks of great intensity, the clinical picture was enriched by ipsilateral lacrima- tion, conjunctival injection, nasal congestion, and rhi- norrhea. Pain typically began gradually, reaching maximal intensity within several hours, lasting from 6 to 24 hours; autonomic signs typically lasted for a few hours. During headache, the patient preferred to remain still, lying down in a dark and quiet room. The mean frequency of headache attacks was 1-2/month, becoming less frequent after menopause until the age of 67 years, when the frequency gradually increased again. When the patient was observed at the age of 69, she complained of a chronic daily headache associ- ated with overuse of non-steroidal anti-inflammatory drugs (NSAIDs). She denied any symptoms of aura, premonitory features, autonomic symptoms, or pain within the attacks. The patient suffered from blood artery hypertension, following appropriate antihyper- tensive therapy. Physical examinations, including neu- rologic examination and detailed laboratory exams, were entirely normal. A brain magnetic resonance imaging (MRI) with gadolinium revealed a malfor- mation of the midbrain characterized by right devia- tion of the medulla oblongata associated with elongation, sinuosity, and ectasia of the basilar and the left vertebral arteries (Figure). The patient was treated with β-blockers and ami- triptyline with gradual reduction of intensity and fre- quency of pain attacks and resolution of NSAIDs overuse. COMMENTS The patient presented with a more than 50-year history of recurrent attacks of strictly unilateral pain. The attacks had some features of migraine without aura but were associated with ipsilateral autonomic signs. Duration and frequency of the attacks were From the Department of Neuroscience and Rehabilitation, University Hospital of Ferrara, Neurology Division, Ferrara, Italy. ISSN 0017-8748 doi: 10.1111/head.12243 Published by Wiley Periodicals, Inc. Headache © 2013 American Headache Society 1