Nicole Soriano had headaches before but nothing like the one that struck in the middle of one summer night. A coincidence led nine days later to Cedars-Sinai Medical Center, where a rare type of migraine was diagnosed and treated - but any moment during that time could have been disastrous.
"Nicole 'dodged a bullet.' Her symptoms were classic for a type of migraine that causes stroke, but it was diagnosed only after she was referred to Cedars-Sinai for something entirely different. From the time the migraine started to the time we began treatment, she was at high risk for stroke," said Patrick D. Lyden, MD, chairman of the Department of Neurology.
The horrible headache struck at 3 a.m. on July 11, 2010. "I woke up with a more severe headache than I had ever had before," said Nicole, who got up and took an over-the-counter drug that usually worked within 20 minutes. This time, the pain only got worse, so the then-16-year-old woke her parents, who called 911.
"She was in excruciating pain - doubled over in pain - dripping wet, pale, kind of numb and tingly, and when the paramedics got here they said, 'Let's get her in (to the hospital) right away,'" Nicole's mom, Marla, recalled.
They took the Calabasas resident to a local hospital where doctors examined Nicole for neurological problems and did a CT brain scan before concluding she was suffering a migraine headache. They gave her a strong pain reliever and let her go home.
But when Marla and her husband, Jacques, picked up a copy of the brain scan to share with Nicole's pediatrician, the image showed an abnormal growth called an arachnoid cyst, which had not been shared with them at the local hospital. Nicole's intense headaches continued to come and go. In addition to light sensitivity, the headaches were accompanied by slight tingling in Nicole's hands, and left arm weakness - symptoms mimicking those of a possible stroke or other serious brain disorder.
To find out more about the arachnoid cyst, Nicole was referred to Cedars-Sinai's Department of Neurosurgery, where MRI and ultrasound scans were done. Moise Danielpour, MD, director of the Pediatric Neurosurgery Program, determined the cyst was harmless - just something to monitor over time. But the new scans showed a blood vessel abnormality that looked similar to an arterial dissection - an area where the inner layer of an artery separates from the wall. Danielpour referred Nicole for further evaluation to Lyden.
"As it turns out, what she really had were very unusual and severe migraines that caused an artery in her brain to spasm. Migraines strong enough to cause arterial spasms can lead to stroke, so we started aggressive treatment with a powerful anti-migraine medication and short-term Plavix to be sure the artery remained open," said Lyden, the Carmen and Louis Warschaw Chair in Neurology.
He said the seriousness of Nicole's migraine was similar to that of Serene Branson, the KCBS reporter who had a sudden and severe migraine that affected her speech during on-air reporting of the Grammy Awards in February. Her mental lapse and inability to express her thoughts led to the belief she had suffered a stroke.
"Stroke incidence is increasing among younger patients, largely due to migraine and arterial dissections. Stroke isn't your grandparents' disease anymore. It can strike at any age, and we all need to pay more attention to stroke warning signs. If you think someone could be having a stroke, don't assume they are too young. Call 911," Lyden said.
Signs of a stroke include:
•Sudden severe headache
•Sudden severe numbness or weakness on one side
•Sudden loss of speech or comprehension
•Sudden severe unsteadiness or dizziness
•Sudden severe loss of vision
Although Nicole, who will turn 18 in November, had not had a migraine before that night in July, she had an experience the previous month that had worried her parents. The Calabasas High School student, who is a member of two choirs and an a cappella group, was in the middle of a performance when she looked ill.
"We noticed while she was on stage that she had become as white as a ghost. She said she was light-headed and feeling like she was going to pass out, and it came out of nowhere. That's when I started to notice that she wasn't herself. She had never done that before. There were 200 other kids there, and it was hot for all of them, but nobody else was about to collapse," Marla said.
Nicole's headaches and symptoms have subsided but she will have follow-up exams and brain scans for the coming months or years. Set to graduate from high school this June and attend college in Boulder, Colo., she is being weaned off the powerful drugs but still takes an aspirin a day to thin her blood while the artery continues to relax and heal. The busy student also is under doctor's orders to not skip meals, Lyden said with a smile.
"Anyone who has a history of severe, complex migraines needs to keep doing whatever works to prevent recurrences. Nicole should be fine as long as she's diligent about preventing her migraines, and in her case that involves remembering to eat and stay well hydrated. For a lot of people, a drop in blood sugar can lead to headaches and migraines," Lyden said.
Cedars-Sinai Medical Center