Abstract 008: Vascular Oddity in Neurology: The Intriguing Nexus Between Persistent Primitive Trigeminal Artery & Migraine Cephalgia

Introduction We present a unique case of female with a presentation of migraine cephalgia in the context of persistent primitive trigeminal artery. Case Presentation A 51‐year‐old woman with hyperlipidemia and chronic migraines presented with acute left facial droop and left upper extremity numbness. Stroke alert was initiated, but imaging and workup were unremarkable. CT angiogram revealed a persistent left trigeminal artery—Saltzman type I, Petrosal variant—originating from the proximal cavernous segment of the left ICA and joining the mid‐basilar artery. She reported a history of childhood headaches that had recently recurred with increased severity, described as stabbing occipital and temporal pain with dizziness, nausea, phonophobia, and photophobia. Bright light worsened symptoms, and OTC medications were ineffective; atogepant had previously provided moderate relief. She was discharged on aspirin for suspected TIA and counselled on migraine prevention strategies, including sleep hygiene, hydration, trigger avoidance, and limited use of short‐acting analgesics. Discussion During embryogenesis, arterial fetal anastomoses connect carotid artery to the vertebrobasilar system via trigeminal, otic, hypoglossal, & proatlantal intersegmental arteries. These vessels typically regress after vertebrobasilar system fully develops. However, persistent trigeminal artery (PTA) is the most common remnant among these anastomoses when they fail to involute. While PTA is usually asymptomatic, it has been associated with clinical manifestations such as sixth or third nerve palsies, vertigo, ataxia, & stroke. Its link to migraine‐like headaches is not well‐established, although emerging literature suggests that intracranial arterial anomalies or vascular malformations may contribute to migraine symptoms. According to the ICHD‐2 classification, migraines can be secondary to other disorders, but cases tied to carotid‐vertebrobasilar anastomoses remain rare. The proposed mechanism involves vertebrobasilar insufficiency & transient vascular steal phenomena, particularly in the presence of intracranial atherosclerotic disease. Additionally, PTA's proximity to trigeminal nerve & Gasserian ganglion may increase neurovascular compression & inflammation, potentially causing neuralgia. Unconventional treatment modalities, including human placental extract combined with subcutaneous testosterone, micronized progesterone, aspirin, amlodipine, & oral NADH, have been documented in the literature for cases where standard approaches fail. Conclusion In conclusion, PTA, among many other anomalies of intracranial vessels, should be considered as a potential cause of migraine‐like headaches. image