What is the most likely diagnosis for a patient with a throbbing headache, visual disturbances, nausea, and vomiting, with a history of hypertension?

Migraine with Aura

The most likely diagnosis is migraine with aura (specifically migraine with visual aura). This patient presents with the classic triad of visual aura (bright shimmering jagged lines), followed by unilateral throbbing headache and nausea with vomiting, which precisely fulfills the ICHD-3 diagnostic criteria for migraine with aura 1.

Diagnostic Reasoning

Key Clinical Features Supporting Migraine with Aura

• Visual aura characteristics: The "bright shimmering jagged lines" represent a classic positive visual phenomenon (fortification spectra or scintillating scotoma) that is pathognomonic for migraine aura 1
• Gradual onset: The aura started gradually, which is characteristic of migraine aura that typically spreads over ≥5 minutes, distinguishing it from sudden-onset vascular events like TIA or stroke 1
• Temporal relationship: The headache followed the visual symptoms within the expected timeframe (aura accompanied by or followed by headache within 60 minutes) 1
• Headache characteristics: Unilateral, throbbing, left-sided headache with nausea and vomiting are classic features meeting ICHD-3 criteria for migraine without aura component 1
• History of prior headaches: The patient has a history of occasional headaches, suggesting recurrent attacks 1

Reassuring Physical Examination Findings

The normal physical examination effectively excludes the dangerous differential diagnoses:

• Normal pupils and funduscopy: Rules out acute increased intracranial pressure, papilledema, and optic neuritis 1
• Normal eye motions: Excludes cavernous sinus thrombosis and cranial nerve palsies 1
• Supple neck: Makes subarachnoid hemorrhage and meningitis highly unlikely 1
• Bilateral visual symptoms: The fact that symptoms occurred "with both eyes" indicates a cortical (occipital lobe) origin rather than monocular retinal or optic nerve pathology 1

Why Other Diagnoses Are Unlikely

Subarachnoid Hemorrhage

• Would present with sudden "thunderclap" headache (maximal intensity at onset), not gradual visual aura followed by headache 1
• Neck stiffness would be expected in 35% of cases 1
• Visual aura with gradual spread over minutes is not characteristic 1

Cavernous Sinus Thrombosis

• Would cause ophthalmoplegia (abnormal eye movements) and cranial nerve palsies, which are absent here 1
• Typically presents with periorbital pain, proptosis, and chemosis 1
• Would not cause bilateral visual field phenomena 1

Optic Neuritis

• Causes monocular vision loss, not bilateral visual phenomena 1
• Associated with pain on eye movement 1
• Would show abnormal funduscopy or pupillary defects 1
• While family history of multiple sclerosis is present, the clinical presentation does not fit optic neuritis 1

Tension-Type Headache

• Does not cause visual aura 1
• Typically bilateral, non-pulsating, mild-to-moderate intensity 1
• Not associated with nausea, vomiting, or visual disturbances 1

Critical Diagnostic Considerations

Hypertension Context

While the patient has hypertension, the normal vital signs and absence of focal neurological deficits make hypertensive emergency with posterior reversible encephalopathy syndrome (PRES) unlikely 2. PRES would typically present with severely elevated blood pressure and altered mental status 2.

Aura vs. TIA Differentiation

The gradual spread of visual symptoms over minutes (rather than sudden simultaneous onset) and the positive visual phenomena (bright shimmering lines rather than negative symptoms like vision loss) clearly distinguish migraine aura from TIA 1. Aura symptoms characteristically spread gradually over ≥5 minutes and occur in succession, whereas TIA symptoms have sudden, simultaneous onset 1.

Red Flags Appropriately Absent

This patient lacks the red flags that would mandate urgent neuroimaging 1, 3:

• No thunderclap headache 1, 3
• No focal neurological deficits on examination 1, 3
• No altered consciousness 3
• No neck stiffness 1, 3
• No fever 3
• Not a new headache in someone over 50 years 3

Clinical Pitfalls to Avoid

Do not mistake migraine aura for stroke or TIA: The gradual spread and positive visual phenomena are key distinguishing features 1. However, if any doubt exists or if focal deficits persist beyond 60 minutes, urgent neuroimaging is warranted 1, 3.

Do not overlook medication considerations: If this patient is taking oral contraceptives (as suggested by the sexual relationship context), migraine with aura increases stroke risk, and alternative contraception should be considered 1.

Do not dismiss the diagnosis based on hypertension: Migraine and hypertension commonly coexist, and the presence of hypertension does not exclude migraine 1.