A "Super Mario" Headache

Author : Preetibah Ratenavelu

Abstract :Brief Clinical History: A 3G year old female presented to the Emergency Department with a two-day history of worsening headache and new visual symptoms described as “flashing coloured lights” in the right eye, likened to “Super Mario” colours. She denied vision loss, trauma, or similar prior episodes. She had a known history of migraines, however neurological examination revealed a right homonymous hemianopia, which was not in-keeping with this. Misleading Elements: The patient’s age, history of migraines along with headache and visual aura-like symptoms, resembled migraine with aura and supported a benign diagnosis. Helpful Details: The key point was a detailed neurological examination that revealed a right homonymous hemianopia. This prompted urgent neuroimaging, which showed a 4.7 cm rim-enhancing lesion in the left occipital lobe, a smaller adjacent lesion, and extensive surrounding edema with mass effect. The patient was admitted for further workup. Differential Diagnosis: The initial diagnosis was focused on migraine with aura, however inconsistent neurological findings led to a switch of clinical suspicion towards a space-occupying lesion. Actual Diagnosis: Metastatic non-gestational choriocarcinoma. Chest X-ray revealed a well-defined mass in the left upper lobe, raising concern for a primary lung malignancy. Serum beta-hCG was markedly elevated, though pregnancy was excluded. The patient underwent craniotomy with resection of the lesion. Histopathology confirmed metastatic choriocarcinoma. Educational and Clinical Relevance: This case highlights the need for vigilance when managing patients with known migraine who present with atypical features or evolving symptoms. The visual field deficit was a key clue, shifting the diagnostic focus away from migraine and towards an intracranial pathology. Early imaging and multidisciplinary input were essential for timely diagnosis and management.

Keywords :Emergency medicine Public health Health disparities Health communication

Conference Name :International Conference on Emergency Medicine and Public Health (ICEMPH-25)

Conference Place Turku, Finland

Conference Date 21st Oct 2025