6.3.2 Headache attributed to arteriovenous malformation (AVM)

Identification: 32-year-old female patient, with no known comorbidities, reports recurrent episodes of unilateral headache for 6 months. History of Present Illness: Recurrent headache (3-4 episodes/month), pulsatile, right-sided hemicrania (intensity 7/10), lasting 4-12 hours. Associated with: Ipsilateral pulsatile tinnitus ("hearing the heartbeat in the right ear"), photophobia, and nausea (without vomiting). No visual or sensory aura. Triggered by: Physical exercise, exertion, or postural changes. No improvement with common NSAIDs. Neurological Examination: Normal (no focal deficits). Cranial auscultation: Systolic bruit over the right temporal region. Fundoscopy: No papilledema or retinal hemorrhages. Complementary Exams: Non-contrast cranial CT: Serpiginous vascular lesion in the right parietal lobe. No acute bleeding. MR angiography/CT angiography: Spetzler-Martin Grade II AVM (3.5 cm) in the right parietal cortex. Well-defined nidus, superficial venous drainage (Rolandic vein). High flow (significant arteriovenous shunt). Cerebral angiography (DSA): Main feeders: Branches of the right middle cerebral artery. Spetzler-Martin Classification: Grade II (size <3 cm, non-eloquent location, superficial drainage).