Dramatic Effect of Botox Injection in Disabling Chronic Migraine Secondary to Inoperable Cerebral Arteriovenous Malformation.

Arteriovenous malformation is a developmental anomaly of the vascular system characterized by arteriovenous shunt through a collection of tortuous vessels without intervening capillary bed. Brain arteriovenous malformations (AVMs) may cause hemorrhagic stroke, epilepsy, and chronic headache. Migraine with aura was reported in up to 58% of females with AVM. A 23-year-old female presented with episodes of severe left-side headache for five months, throbbing in character with photophobia, phonophobia, and nausea. Brain MRI showed a large AVM in the left cerebellar hemisphere. She was diagnosed with grade six AVM, which is inoperable, and secondary migraine. Her migraine symptoms didn't respond to oral medications. However, it responded dramatically to Botox injections. Seven days after Botox injection, her headache disappeared, and her well-being improved. Three years post-diagnosis and treatment, she got married, then three months later became pregnant. During pregnancy, she followed up with neurology, obstetrics, and gynecology. She was delivered by cesarean section to minimize the risk of intracranial hemorrhage and delivered without complications. The female patient in this case with migraine secondary to inoperable brain AVM treated with Botox; she got married and delivered by C-section without complications. This case raises the following important lessons: large AVMs can present with migraine only, and Botox has a dramatic effect on the treatment and the ability to have a safe pregnancy and delivery in large AVM cases.