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2A Clinic
Clinical Case for Discussion: Migraine
Patient Information and Chief Complaint (Faculty reports to student)
18 year old female; “headache”
What is the differential diagnosis?
Tension type headache
Migraine headache with aura
Migraine headache without aura
Trigeminal neuralgia or other trigeminal autonomic cephalgia
Sinus headache
Meningitis
Head trauma
Intracranial hemorrhage, subarachnoid hemorrhage or other cerebrovascular disorder
Cluster headache
Preliminary Case Information(Faculty reports to student)
An 18-year-old female with no significant past medical history presents to the clinic with 3 hour history of
right-sided headache. The patient reports she was in her usual state of health until this morning when
she awoke feeling irritable and tired. Approximately 3 hours ago she began to experience right-sided
headache that worsened over 1 hour and has been persistent since that time. The patient describes the
headache as throbbing and worsens with physical activity. The headache is less severe with rest and
when in a dark room. No other alleviating factors and she has not taken any medication.
What is the differential diagnosis?
Tension type headache
Migraine headache with aura
Migraine headache without aura
Trigeminal neuralgia or other trigeminal autonomic cephalgia
Sinus headache
Meningitis
Head trauma
Intracranial hemorrhage, subarachnoid hemorrhage or other cerebrovascular disorder
Cluster headache
What is the most likely diagnosis?
Migraine headache with or without aura
What other historical information is essential?
Assess for other migraine prodrome symptoms: euphoria, depression, irritability, food cravings,
constipation, neck stiffness, and increased yawning
Assess for symptoms of migraine aura:
 Positive : visual (eg, bright lines, shapes, objects), auditory (eg, tinnitus, noises, music),
somatosensory (eg, burning, pain, paresthesia), or motor (eg, jerking or repetitive rhythmic
movements)
 Negative: absence or loss of function, such as loss of vision, hearing, feeling, or ability to move a
part of the body
Assess for associated symptoms and life-threatening causes of headache: nausea, vomiting,
phonophobia, photophobia, worst headache of life, associated with focal neurologic deficits (confusion,
decreased level of consciousness, visual disturbance, weakness, sensory loss, incoordination), fever, stiff
neck
Assess prior history: similar symptoms, head trauma, and family history of headache disorder
Assess for precipitating and exacerbating factors: stress, menstruation, visual stimuli, weather changes,
nitrates, fasting, and wine
Additional Case Information(Faculty reports to student)
The patient reports she also experienced tingling on the ride side of the face and blurring of vision in her
right eye for about 5-10 minutes when the headache was beginning. Those symptoms have since
resolved. Reports mild nausea without vomiting. Reports phonophobia and photophobia. Patient denies
confusion, decreased level of consciousness, visual disturbance, weakness, sensory loss, incoordination,
fever, neck stiffness. She reports prior history of headaches once or twice per year since age 16 that are
of similar character, either on the right or left side, and typically resolved within 5-6 hours. No history of
head trauma. She is uncertain if anyone in her family has a headache disorder. She does not know if
prior headaches were precipitated by a specific factor.
What is the differential diagnosis?
Tension type headache
Migraine headache with aura
Migraine headache without aura
Trigeminal neuralgia or other trigeminal autonomic cephalgia
Sinus headache
Meningitis
Head trauma
Intracranial hemorrhage, subarachnoid hemorrhage or other cerebrovascular disorder
Cluster headache
What is the most likely diagnosis?
Migraine headache with aura
What elements of the physical exam should be included?
Vital Signs with Pain Score
HEENT Exam
Cardiac Exam
Pulmonary Exam
Neurologic Exam
Additional Case Information (Faculty reports to student)
Physical Exam remarkable for normal vital signs, pain score 7/10, cutaneous allodynia with light
palpation of right scalp, no papilledema and no focal neurologic deficits.
What is the most likely diagnosis?
Migraine headache with aura
What diagnostic tests are indicated?
Neuroimaging is not necessary in most patients with migraine. Evidence-based guidelines issued by the
American Academy of Neurology suggest considering neuroimaging in the following patients with nonacute headache:
●Patients with an unexplained abnormal finding on neurologic examination
●Patients with atypical headache features or headaches that do not fulfill the strict definition of
migraine or other primary headache disorder (or have some additional risk factor, such as
immune deficiency)
Patients with sudden severe headache also need neuroimaging because of the suspicion of
subarachnoid hemorrhage. The following clinical situations may warrant neuroimaging:
●The “first or worst” headache
●Recent significant change in the pattern, frequency or severity of headaches
●New or unexplained neurologic symptoms or signs
●Headache always on the same side
●Headaches not responding to treatment
●New-onset headaches after age 50 years
●New-onset headaches in patients with cancer or HIV infection
●Associated symptoms and signs such as fever, stiff neck, papilledema, cognitive impairment, or
personality change
A head CT scan (without and with contrast) is sufficient in many patients when neuroimaging is deemed
necessary. An MRI is indicated when posterior fossa lesions or cerebrospinal fluid (CSF) leak are
suspected. Magnetic resonance angiography (MRA) and magnetic resonance venography (MRV) are
indicated when arterial or venous lesions, respectively, are considered in the differential diagnosis. No
other diagnostic tests are typically necessary in patients with suspected migraine.
What is the most likely diagnosis?
Migraine headache with aura
What are the diagnostic criteria for the most likely diagnosis?
International Classification of Headache Disorders, 3rd edition (ICHD-3)
The ICHD-3 criteria for migraine with aura are as follows
A) At least two attacks fulfilling criterion B and C
B) One or more of the following fully reversible aura symptoms:
•Visual
•Sensory
•Speech and/or language
•Motor
•Brainstem
•Retinal
C) At least two of the following four characteristics:
•At least one aura symptom spreads gradually over ≥5 minutes, and/or two or more symptoms
occur in succession
•Each individual aura symptom lasts 5 to 60 minutes
•At least one aura symptom is unilateral
•The aura is accompanied, or followed within 60 minutes, by headache
D) Not better accounted for by another ICHD-3 diagnosis, and transient ischemic attack has been
excluded
What is your approach to treatment?
●Educate migraine sufferers about their condition and its treatment and encourage them to
participate in their own management
●Use migraine specific agents (eg, triptans, dihydroergotamine) in patients with more severe
migraine and in those whose headaches respond poorly to NSAIDs or combination analgesics
●Select a nonoral route of administration for patients whose migraines present early with
significant nausea or vomiting
●Consider a self-administered rescue medication for patients with severe migraines that do not
respond well to other treatments
●Guard against medication overuse headache by using prophylactic medications in patients with
frequent headaches
Reference
UpToDate