BACKGROUND
Duplicated middle cerebral artery (DMCA) is an uncommon congenital arterial variant. Its relationship to primary headache is uncertain, and cranial autonomic symptoms in migraine may complicate its differentiation from trigeminal autonomic cephalalgias.
CASE REPORT
A 30-year-old woman had a 15-year history of strictly left temporal-periorbital pulsating headaches, typically occurring approximately once monthly and lasting 2 to 72 hours, accompanied by nausea, vomiting, photophobia, and phonophobia. After sleep disruption, the headaches progressed to a daily nocturnal pattern lasting 3 weeks. The duration of individual nocturnal attacks during this recent phase was not reliably documented. The attacks awakened her from sleep and were accompanied by ipsilateral lacrimation, conjunctival injection, nasal congestion, and rhinorrhea. Magnetic resonance angiography revealed a left Teal type A DMCA, and magnetic resonance venography revealed right transverse-sigmoid sinus hypoplasia with left-dominant venous drainage. No parenchymal lesion, aneurysm, arterial stenosis, hemorrhage, epileptiform abnormality, or cardioembolic source was identified. The clinical diagnosis was migraine with a recent daily exacerbation and prominent cranial autonomic symptoms. Treatment with flunarizine, low-dose amitriptyline, and gabapentin, as well as lifestyle modifications, was followed by substantial improvement. At 3 months, headache frequency had decreased to fewer than 1 attack per month, and the Headache Impact Test-6 score had improved from 58 to 46.
CONCLUSIONS
Migraine with prominent cranial autonomic symptoms can mimic trigeminal autonomic cephalalgia. Coexisting arterial and venous variants may be incidental. This single case does not establish causality or the general diagnostic utility of detailed vascular imaging.

Keywords: Migraine Disorders; Duplicated Middle Cerebral Artery; Migraine; Cranial Autonomic Symptoms; Venous Sinus Hypoplasia; Case Report