A 20 year old unmarried girl complaining of visual aura lasting for 20 minutes described as a small central disturbance in the field of vision marches towards the periphery, leaving a transient scotoma in its wake. The expanding border of that has a scintillating, dancing, or zigzag edge. This phenomena also remain visible in the dark or with the eyes closed. After the visual symptoms recede, headache develops. She gives a long standing history of stereotypic attacks. What is the most likely diagnosis?

**Core Concept:** Migraine is a common primary headache disorder characterized by recurrent, unilateral, pulsating headaches often accompanied by visual and sensory symptoms. Visual aura is a common manifestation, described as a scintillating scotoma and is usually accompanied by headache.

**Why the Correct Answer is Right:** The correct answer is migraine (Option C) because the patient is describing typical migraine symptoms. The visual aura, described as a 'small central disturbance in the field of vision marches towards the periphery, leaving a transient scotoma in its wake' is a common migraine symptom. Additionally, the scintillating, dancing, or zigzag edge of the expanding border and the fact that the visual symptoms remain visible in the dark or with the eyes closed are also consistent with migraine.

**Why Each Wrong Option is Incorrect:**

A. Ischemic stroke (Option A) is usually characterized by sudden onset, severe headache, and focal neurological deficits. Visual aura in ischemic stroke is usually described as a large, sudden, and persistent visual deficit, not a small, progressive visual disturbance.

B. Transient ischemic attack (Option B) is similar to ischemic stroke but is considered less severe and usually recovers spontaneously within 24 hours. Migraine visual aura, however, can last up to 60-90 minutes and is not usually accompanied by headache.

D. Hemiplegic migraine (Option D) is a rare form of migraine that presents with aura involving one side of the body along with the headaches. The described visual aura in this question does not match the typical presentation of hemiplegic migraine.

**Clinical Pearl:** Migraine is a common neurological disorder affecting approximately 10% of the population. The visual aura described in this question is a common manifestation of migraine, and recognizing these symptoms can help differentiate it from other neurological disorders with similar symptoms like stroke or transient ischemic attack.

✓ Correct Answer: B. Classic migraine