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Migraine with typical aura — MSRA MCQ

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ModerateMRIMigraine with typical auraMSRA

A 38-year-old woman asks her GP for a brain MRI because her sister was recently diagnosed with a glioblastoma. For 10 months, she has had approximately 2 attacks per month. Each begins with shimmering zig-zag lines in both visual fields that gradually expand over 15 minutes and resolve completely within 25 minutes. This is followed by a unilateral throbbing headache lasting up to 12 hours, with nausea, photophobia and phonophobia. The attacks are stereotyped and have not changed in frequency or character. She has no weakness, sensory loss, dysphasia, cognitive change, seizure, fever, vomiting outside attacks, head trauma, or history of malignancy. Neurological examination and fundoscopy are normal. What is the most appropriate management plan?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: A — Diagnose migraine with typical aura and do not arrange neuroimaging solely for reassurance

Explanation lettering: B = shown as A · A = shown as B · D = shown as C · C = shown as D

This is migraine with typical aura: the visual symptoms are positive, gradual in evolution, completely reversible and followed by a characteristic migrainous headache. The attacks are recurrent, stereotyped and stable over 10 months. There are no features suggesting secondary headache, such as sudden maximal-onset headache, progressive focal neurological deficit, cognitive change, impaired consciousness, recent head trauma, headache triggered by Valsalva or exercise, unexplained vomiting, immunosuppression, or a personal history of malignancy that commonly metastasises to the brain. NICE advises against neuroimaging solely for reassurance in people diagnosed with migraine who lack symptoms or signs of another cause. A family history of glioblastoma alone does not alter this recommendation. Therefore, explanation, reassurance and migraine management are appropriate. A and D are inappropriate because there is no urgent imaging indication. C is tempting because of understandable anxiety about a first-degree relative with a brain tumour, but routine MRI is not indicated on this basis in an otherwise typical stable migraine presentation. E would be appropriate if there were diagnostic uncertainty, atypical aura, a substantial change in headache characteristics or a focal neurological abnormality, none of which is present.

Reference: NICE CG150: Headaches in over 12s: diagnosis and management — Recommendations (Last updated 3 June 2025) — https://www.nice.org.uk/guidance/cg150/chapter/Recommendations