Acephalgic Migraine Presenting as Episodic Fatigue and Nausea: A Case Report.

Acephalgic migraine (AM), or migraine aura without headache, is a subtype of migraine, characterized by transient neurological symptoms without the accompanying headache phase. Its diagnosis remains challenging due to varied clinical presentation and the tendency to misattribute symptoms to other neurological, psychiatric, or systemic disorders. This case report describes a female patient, age 38 years, presenting with episodic, incapacitating fatigue, nausea, and cognitive dysfunction, initially leading to an extensive but inconclusive diagnostic workup. Partial symptom relief with ondansetron, but not with metoclopramide, suggested involvement of migraine-associated pathways. A detailed history revealed a family history of migraine and specific triggers, including dietary and hormonal factors. A therapeutic trial with triptans led to dramatic symptom resolution, supporting an AM diagnosis. Retrospectively, the patient was able to identify additional aura symptoms, reinforcing the diagnosis. This case underscores the diagnostic challenge of AM and migraine aura variants. It also highlights the pivotal role of careful history-taking, patient-physician communication, and clinical reasoning in the evaluation of atypical symptom presentations. Clinician awareness of migraine spectrum disorders is essential to prevent misdiagnosis, reduce unnecessary testing, and improve patient outcomes. Further research is needed to refine diagnostic criteria and optimize management strategies.