brainstem vascular malformations can be classified as arteriovenous malformations , venous malformations , cavernous malformations , or capillary telangiectasias . on pathological examination ,
capillary telangiectasias are a distinct type of vascular malformation , characterized by multiple thin - walled vascular channels , interposed between normal brain parenchyma .
it has been postulated that telangiectasias are acquired lesions , caused by other underlying venous anomalies .
, numerous case reports of presumed brainstem capillary telangiectasias have appeared ; usually pathological confirmation is absent .
the fact that most capillary telangiectasias are found incidentally on mr imaging confirms the suggested clinically benign course in general , although a histopathologically proven , clinically aggressive case in an infant has been described .
we performed a pubmed search of the literature and found 26 cases to date [ 58 ] .
all but one of these cases were thought to be symptomatic , including symptoms of vertigo , tinnitus , hearing loss , ataxia , limb paresthesias , and monocular ptosis .
basilar - type migraine , previously called basilar migraine or bickerstaff migraine , is a migraine variant first described by bickerstaff in 1961 .
being a very rare migraine variant , the exact incidence and prevalence are unknown . although various criteria for the diagnosis have been applied over the years , fully reversible symptoms resulting from brainstem dysfunction are essential for the diagnosis .
a recent study found the median age of onset to be 17  years and a female - to - male ratio of 3.8:1 .
an 18-year - old woman presented to the outpatient clinic with a history of unilateral headaches , accompanied by phonophobia , but no photophobia , nausea , or vomiting .
these headaches had increased in frequency over the last 6  months from once per year to about three times per week , typically lasted several hours , and were alleviated by sleep .
the headache was frequently preceded by visual symptoms , such as flickering or black spots , in both visual fields .
the patient had not used painkillers for these attacks , because in her opinion , these headaches were not severe enough to justify the use of medication . furthermore , this patient experienced a single episode of vertigo , followed by sudden loss of consciousness with a duration of about 10  min .
no jerks , urinary incontinence , or tongue bite were present . on regaining consciousness , no confusional state was present , but patient noted the most terrible headache ever .
several days later , an attack of vertigo without hearing loss occurred , with alternating paresthesias in all limbs , followed by the same terrible headache . for these
a clinical diagnosis of basilar - type migraine was made , since the patient fulfilled the international headache society ( ichd - ii ) criteria .
magnetic resonance imaging ( mri ) showed focal areas of hyperintensity in t2-weighted spin echo images , hypointensity in t2 * -weighted gradient echo images , and enhancement in postcontrast t1-weighted images ( fig .  1 ) .
the diagnosis was revised to secondary headache attributed to cranial vascular disorder ( ichd - ii 6 ) , since one of the criteria for basilar - type migraine is that it can not be attributed to another disorder .
she was treated with propranolol 80  mg per day as prophylactic treatment and acetaminophen 1,000  mg during attacks . during follow - up
, she reported excellent response to the propranolol , with no new basilar - type migraine attacks for 12  months.fig . 
1postcontrast axial and sagittal t1 , arrows pointing towards mr - suggested capillary telangiectasia postcontrast axial and sagittal t1 , arrows pointing towards mr - suggested capillary telangiectasia
although no pathologic confirmation is available in our patient , we believe the radiological abnormality found on mri to be a capillary telangiectasia . this is supported by the absence of significant changes in a follow - up mri scan .
the association with clinical symptoms remains unproven , although a clinical picture of  peculiar attacks of prolonged loss of consciousness  due to pontine telangiectasia has been described in the literature .
another paper describes a case of basilar - type migraine associated with calcifications in the pontine tegmental nuclei . as this case illustrates , mr imaging of the brain
should be considered if a rare cause of primary or secondary headache is suspected on clinical grounds .
follow - up imaging seems only to be warranted in presumed symptomatic lesions , although the added value remains debatable , since no therapeutic interventions are available .
regarding preventive treatment for basilar - type migraine , some experts prefer divalproex - sodium or verapamil instead of propranolol because of the concern of limitation of compensatory vasodilatory mechanisms . in our opinion no contraindication for propranolol exists in this patient because of the assumed causal relationship between the capillary telangiectasia and her clinical symptoms . with respect to acute treatment
, there seems to be consensus against triptans because of concern over the potential for cerebral vasoconstriction and the uncertainty of the mechanism of basilar - type migraine , although evidence proving this causality is lacking . in conclusion , with this case report we provide some further evidence that pontine capillary telangiectasia might cause a clinical picture resembling basilar - type migraine .
 a case of presumed pontine capillary telangiectasia in an 18-year - old woman with a clinical diagnosis of basilar - type migraine is reported . 
 since both are very rare diagnoses , this case provides some evidence to suggest that pontine capillary telangiectasia might cause a clinical picture resembling basilar - type migraine . 
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