Timothy C. Hain, MD Page last modified: November 16, 2009
A woman in her 40's presented withdizziness, imbalance and headaches. There were 5 years of symptoms, provoked by a combination of stress and the time of the month. Before the symptoms, she became flushed, tired and have a headache. There has been a history of migraine headaches roughly since the age of 10.
The general examination was normal. Under video frenzel goggles there was a minor upbeating nystagmus on head right, but nothing on head left. Hyperventilation provoked a weak left-beating nystagmus. Valsalva testing was normal.
This patient has classic signs and symptoms of migraine as well as the physical findings of mild BPPV. Nevertheless, in addition to treatment aimed at migraine, she was sent for an MRI of the brain.
Her MRI showed a tumor of the cerebellum. A sterotaxic biopsy suggested that this is a cerebellar neurocytoma. This is a rare tumor, that mainly occurs in other locations close to the lateral ventricles. More about neurocytoma can be found here.
In this patient, had no MRI been done, it seems likely that she would have deteriorated neurologically and done worse. Thus there is a risk of missing the diagnosis of a more serious problem in migraine. This example leads one naturally to wonder whether or not individuals making this diagnosis acting without physician oversight, may need more comprehensive malpractice insurance than those who are not.