Learning Objectives
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Learn the common types of headache.
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Develop an understanding of clinical presentation of specific headache types.
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Learn to identify prodrome and aura.
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Develop an understanding of the treatment of specific headache types.
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Develop an understanding of the differential diagnosis of headache.
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Develop an understanding of the treatment options for specific headache types.
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Learn how to identify factors that cause concern.
Stephanie Ellison
I tried to help Stephanie calm down, and after she tried to vomit a couple more times, I asked her if she had identified anything that triggered her headache and she immediately answered, “My periods.” She continued, “I also sometimes get them when my sleep is messed up or when I have the stress of a deadline.” I asked her if she was ever woken up with a headache, and she said no, but they often occurred in the morning. “They also got worse when my gynecologist changed my birth control pills because my insurance changed.” I asked if anyone else in her family had similar headaches and she said that both her mom and her aunt had the same headaches, but they got better with menopause. I asked if she knew that she was going to get a headache before it actually started and she said, “Absolutely. It’s the craziest thing. When I am going to have a headache, it feels like everything looks like it is in a high-definition movie with the subwoofers turned all the way up. I then start to get really sensitive to the light of my computer screen, everything is too loud, and any strong odors make me want to gag. The other crazy thing is that I can’t stop yawning. It drives my boyfriend crazy. I just keep yawning over and over again even though I am not tired. Then my vision in my left eye gets all jiggly and shimmery and glittery and I know I am really in trouble. I still don’t have any headache, but I know that there is no going back. I’ve tried all of the usual over-the-counter medications like Excedrin Migraine and those Imitrex shots, but once the eye thing gets going, nothing works to stop the headache.” I asked if she had any weakness associated with her headache and she said, “No, just the eye thing, and the nausea and vomiting. I’ve gotten so dehydrated from the vomiting that I have ended up in the ER a bunch of times. I heard one of the nurses tell the ER doctor that I was a frequent flyer…as if I had a choice!” She started crying again. I asked if she experienced smells that nobody else could smell or if she had any difficulty finding words or speaking, and she again said no. “Look, Doctor, I’m not making this stuff up.” I told her that I believed her and thought that I had a pretty good idea what was going on.
I asked her what made it better and she said that really nothing worked once the headache got going. Sometimes the shot of demerol and phenergan they gave her in the ER let her go home and sleep the headache off. She started crying and said, “Doctor, what am I going to do? Do you think I have a brain tumor? That’s what my boyfriend says!”
I asked Stephanie to use one finger to point at the spot where it hurt the most. She pointed to her left temple. I asked her what the pain was like—an ache, sharp, stabbing, burning—and she immediately said, “throbbing.” I asked whether the headache was on both sides or just one side, and she immediately answered, “It’s always on my left side.” I asked Stephanie from the time that she knew that she was going to get the headache until the time it was at its worst, was it a period of seconds, minutes, or hours, and she said, “It is always at least a couple of hours before it’s the worst.”
I asked Stephanie if I could examine her and she said, “You can pull out a couple of toenails if you can get rid of my headaches.” I smiled and said that I hoped that would not be necessary. On physical examination, Stephanie was afebrile. Her respirations were 16 and her pulse was 84 and regular. Her blood pressure was 126/80. There were no cranial abnormalities, and her ears and throat were normal. When I grabbed my ophthalmoscope to examine Stephanie’s eyes, she asked in a weak voice, “Do you have to shine that light in my eyes? I am really sensitive to light with my headaches.” I told her I would be as quick as I could, but that I really need to check things out. Her pupils were round, equal, and reactive to light. It took a little effort to perform a fundoscopic examination because Stephanie kept pulling away from the light. I reassured her and was happy to note that there was no papilledema. Her cardiopulmonary examination was normal, as was her thyroid. Her abdominal examination revealed no abnormal mass or organomegaly, but she was a little tender to palpation from all the vomiting. No rebound tenderness was present. There was no costovertebral angle (CVA) tenderness. There was no peripheral edema. A careful neurologic examination of the upper and lower extremities revealed there was no evidence of weakness, lack of coordination, or peripheral or entrapment neuropathy, and her deep tendon reflexes were normal. Stephanie’s mental status exam was within normal limits.
Key Clinical Points—What’s Important and What’s Not
The History
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Episodic headaches entire adult life
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Headaches are unilateral
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Character of pain of the headaches is throbbing in nature
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Headaches are preceded by a prodrome consisting of changes in the quality of vision and hearing and aversion to strong odors, as well as persistent yawning
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Patient experiences a painless prodrome consisting of visual disturbance and photophobia
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Patient denies olfactory aura, weakness, or speech difficulties
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No fever or chills
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Notes significant nausea and vomiting associated with the onset of pain
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Significant disability associated with headaches
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Headaches associated with menstruation
The Physical Examination
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Patient is afebrile
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Normal fundoscopic exam
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Examination of the cranium is normal
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Neurologic exam is normal other than photophobia
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Frequent vomiting during examination
Other Findings Of Note
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Normal cardiovascular examination
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Normal pulmonary examination
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Normal abdominal examination
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No peripheral edema
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Normal upper and lower extremity neurologic examination, motor and sensory examination
What Tests Would You Like to Order?
The following test was ordered:
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Magnetic resonance imaging (MRI) of the brain
Test Results
The MRI of the brain was normal.
Clinical Correlation—Putting It All Together
What is the diagnosis?
Migraine with aura
The Science Behind the Diagnosis
Clinical Syndrome
Migraine headache is a periodic unilateral headache that may begin in childhood but almost always develops before age 30 years. Attacks occur with variable frequency, ranging from every few days to once every several months. More frequent migraine headaches are often associated with a phenomenon called analgesic rebound. Between 60% and 70% of patients who suffer from migraine are female, and many report a family history of migraine headache. The personality type of migraineurs has been described as meticulous, neat, compulsive, and often rigid. They tend to be obsessive in their daily routines and often find it hard to cope with the stresses of everyday life. Migraine headache may be triggered by changes in sleep patterns or diet or by the ingestion of tyramine-containing foods, monosodium glutamate, nitrates, chocolate, wine, or citrus fruits. Changes in endogenous and exogenous hormones, such as with the use of birth control pills, can also trigger migraine headache, as can the ingestion of nitroglycerine for angina. The typical migraine headache is characterized by four phases: (1) the prodrome, (2) the aura, (3) the headache, and (4) the postdrome ( Fig. 2.1 ). Some migraineurs will experience a premonition or warning that a migraine may be on the horizon. This premonition or warning is known as a prodrome and may manifest as mood changes, food cravings, frequent yawning, changes in libido, and constipation. Approximately 20% of patients suffering from migraine headache also experience a neurologic event called an aura before the onset of pain. The aura most often takes the form of a visual disturbance, but it may also manifest as an alteration in smell or hearing; these are called olfactory and auditory auras, respectively. Following a migraine headache, some patients will experience a period of confusion, dizziness, weakness, or elation known as a postdrome. While the exact pathophysiology of migraine has not been elucidated, it appears that that the symptoms and pain associated with migraine headache are the result of functional abnormalities in multiple parts of the central nervous system, as depicted in Fig. 2.2 . Other factors, including migraine-associated genes, hormones, environment, stress, and neuroendocrine function may also play a role ( Fig. 2.3 ).
Signs and Symptoms
Migraine headache is, by definition, a unilateral headache. Although the headache may change sides with each episode, the headache is never bilateral at its onset. The pain of migraine headache is usually periorbital or retro-orbital. It is pounding, and its intensity is severe. The time from onset to peak of migraine pain is short, ranging from 20 minutes to 1 hour. In contradistinction from tension-type headache, migraine headache is often associated with systemic symptoms, including nausea and vomiting, photophobia, and sonophobia, as well as alterations in appetite, mood, and libido. Menstruation is a common trigger of migraine headache.
As mentioned, in approximately 20% of patients, migraine headache is preceded by an aura (called migraine with aura). The aura is thought to be the result of ischemia of specific regions of the cerebral cortex. A visual aura often occurs 30 to 60 minutes before the onset of headache pain; this may take the form of blind spots, called scotoma, scintillation, or a zigzag disruption of the visual field, called fortification spectrum ( Figs. 2.4 and 2.5 ). Occasionally, patients with migraine lose an entire visual field during the aura. Auditory auras usually take the form of hypersensitivity to sound, but other alterations of hearing, such as sounds perceived as farther away than they actually are, have also been reported. Olfactory auras may take the form of strong odors of substances that are not actually present or extreme hypersensitivity to otherwise normal odors, such as coffee or copy machine toner. Migraine that manifests without other neurologic symptoms is called migraine without aura.
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