Age: 59.0
Sex: F
Vaccine: COVID19
Symptoms: Magnetic resonance imaging, Retinal haemorrhage, Sleep disorder, Vision blurred, Visual impairment
Clinical narrative: 2/13/21 @ 4:45 pm Severe intermittent Headaches began at the 4 hour mark after shot  Prescription pain medications 24/7 did NOTHING to help the debilitating headache pain  2/13/21 Severe Pain in right wrist for 4 hours, chills, for 3 days after shot; but did not continue after the 3 days. Headaches began to get stronger and there was less time in between them; my right ear began to have intermittent fluttering inside; this went on day and night - I could not sleep with the severe headaches and the inner ear noise - both progressively got worse through 3/1/21 when I called ophthalmologist  and complained about my vision becoming blurry and blocked vision in right eye. 3/2/21 ophthalmologist appt revealed a retinal he. CONT: retinal hemorrhage in the right eye and a large floater break off tissue in same eye that  blocked vision.  She did not know if that was connected to the vaccine however I will note that at my annual eye exam with her last Sept 2020; I have NONE of these issues. She told me to come bck in 2 wks to see if bleed continues or gets absorbed and to contact my Doctor ASAP about the headaches as I was crying in pain while in her office. 3/3/21 I began an extremely severe headache @ 2:30 am, did not subside and was taking max amount of pain meds 6x 500 mgs of tylenol per day and 2x Naproxyn 500 mg 2x/day - called my cardiologist as her was the last Dr to see me in person on2/5/21 the week before my 2nd Moderna vaccine on 2/13/21 The triage nurse at the practice asked me questions, then said to come in at 4p, then my Dr heard, and said to come in ASAP - I got to his office at 11am; he came in exam room, took one look at me; and sent me to Hospital Emergency  Still, on 3/3/21, I went to ER with Dr having phoned them in advanced - I had a CT scan of the brain area - they tried IV pain meds but they did not work - they sent me home with referral to Neurologist. THIS WAS NOT MY CHOICE - I had to wait from 3/3/21 with referral from hospital to Dr  neurologist in the hospital system BUT Diagnostic would NOT allow me to make appt with him until they had another referral as well - You CANT make this  stuff up. Finally I had my cardiac Dr/Surgeon send their office a referral and was able to make appt. YES I SUFFERED GREATLY from 3/3/21 in the ER to 3/25/21 on appt day - I wanted and almost went to ER 2 other times inbetween but they couldn't do anything the first time that helped. 3/22/21 Followup appt with ophthalmologist, the retinal hemorrhage in right eye was being absorbed - good news, the floater was still an issue but nothing could be done. I filled her in on the ER visit etc. 3/25/21 First appt with Neurologist after exam and noting my timeline and ER results of which he had access to being with Hospital he prescribed the AMITRIPTYLIN and ordered 2x MRI's of my head. He suspected that this was an "auto-immune" response to the Moderna vaccine. He told me the medication would hopefully help the severity of the headaches and/or duration. Began that night taking the AMITRIPTYLIN and am still on it. 3/26/21, 2x MRI's of the head a Touchstone Imaging. 4/5/21 followup with Neurologist - the MRI's did not show any current clots in the large vessels; I still had headaches although they were hurting the AMITRIPTYLIN kept them tolerable and that medication also makes me drowsy and heavy sleep so I was much better off with the AMITRIPTYLIN as I could not function without it at all. The Dr wanted an additional 2x MRIs of the smaller vessels to completely rule out any clots that could be in those areas 4/6/21 2x MRI's of the smaller vessels at Touchstone Imaging  4/7/21 appt with my gastroenterologist [every  6 months] as one of my underlying conditions and reason for disability is idiopathic acute re-occurring pancreatitis [confirmed diagnosed 1997] this condition makes it difficult for me to digest many oral prescription medications so it adds a layer of difficulty in treatments not to "induce" a pancreatic episode.  My gastro Dr has had me as a patient since 1997 and knows me well - went over all the Moderna issues and he was ok with the meds. 4/8/21 call from Neurologist that the last 2x MRI's of the smaller vessels were clear - no clots - a HUGE relief - he said to continue the AMITRIPTYLIN which dulls the nerve sensing pain; saying being an "auto-immune" response, that IF this Moderna vaccine follows other types of vaccines auto-immune responses, that the severe headaches will hopefully subside from 4-6 months and that I would continue the medication until there are no further headaches. CURRENTLY - I have been taking the AMITRIPTYLIN since 3/25/21 - I still have some severe headaches "push through" However, they are intermittent - I cannot up the dose of the AMITRIPTYLIN as I am already having difficulties with the meds side effects, drowsy and sleepy, dry mouth and eyes, low energy, etc - there is no choice, the meds or crying with headache pain;  FUTURE I have 6/14/21 followup appt with neurologist - that will be the 4 month mark after Moderna 2 vaccine, I pray the  headaches are gone but as of now; they are still with me. OH note, as soon as I began the AMITRIPTYLIN, the ear fluttering  stopped within 2 wks, yay! I also have to carry water for the dry mouth and I use lubricating drops for the dry eyes. Doable!