Putting your headache knowledge to practice with three clinical cases

A 46-year-old woman comes to see you complaining of headaches. The headaches occur mostly, but not always, at the left forehead and temple. The character of the pain is pulsating, and she grades the severity as 7–8 out of 10.

The headaches start after she experiences a visual cloud appearing toward the right visual field, which grows and moves across her vision before disappearing within 15 minutes. Her headaches last for several hours and are usually gone after she sleeps. She has about four of these headaches a month. She occasionally experiences nausea but no vomiting. She is unable to do her usual tasks as this increases the headache. Light bothers her eyes.

Characterizing the headache

The character of the headache pain, its severity, localization, and associated complaints are the keys to diagnosis of this clinical case.

Location: unilateral

Pain characteristics: throbbing

Intensity: severe

Associated complaints: nausea and photophobia, positive visual aura, and exacerbated by usual activity

Diagnosis

This patient has the criteria to correctly diagnose a migraine headache with aura.

Approach to treatment

If her examination was otherwise normal, you do not need to order imaging, especially if she had headaches before.

Given the diagnosis of migraine headache with aura, you would have her identify potential migraine triggers and ask her to try to avoid those potential triggers. Have her download a smart phone headache diary app to allow her to record details of her headaches.

If she had more than three headaches a month, you could discuss prophylactic regimens, and recommend magnesium oxide and riboflavin. If the frequency of headaches were higher than three per month, you could recommend topiramate prophylaxis and prescribe a triptan for abortive use.

A 29-year-old woman presents with frequent stress headaches, beginning three months ago. She has been treated for anxiety in the past.

She states that she has had headaches since her teens and with a recent job change, they have become more frequent, occurring two to three times per week. The headaches have also been increasing in both intensity and frequency. She reports the pain severity as 5 out of 10. The headaches are bilateral, with a steady aching pain. They last all day and will sometimes linger into the next day.

She does not have light sensitivity, nor does she experience nausea.

She has been able to continue with her work and activities.

Characterizing the headache

Location: bilateral

Pain characteristics: aching and steady (non-throbbing)

Associated complaints: none (it is not worse with activity and no photophobia or nausea occur)

Diagnosis

This patient experiences tension-type headaches.

Approach to treatment

If her examination is otherwise normal, do not ask for further testing unless she fails treatment or there are further changes.

To follow this closely, you could ask her to download a headache diary app or to keep a paper diary.

Her headache frequency warrants consideration for a prophylactic regimen. You could suggest an antidepressant for this purpose—perhaps a tricyclic or selective serotonin reuptake inhibitor (SSRI)—to aid in addressing her anxiety. For symptomatic pain, you would prescribe a nonsteroidal anti-inflammatory drug (NSAID).

A 52-year-old man presents with a six-year history of recurrent headaches. Each fall, he experiences nearly daily headaches that occur around two o’clock each morning. These awaken him with severe pain, and last from 30 to 50 minutes. Occasionally he will experience more than one event. These bouts of headache will occur for two to four weeks, and then he is symptom-free for months at a time.

There is reddening and conjunctival injection (hyperemia) of his left eye vessels, tearing of that eye, and left-sided nasal congestion. He paces up and down the hall of his home during an event.

Characterizing the headache

Location: unilateral supraorbital

Pain characteristics: severe

Duration: short

Frequency: daily (more than once per day)

Course: In this case, the temporal pattern of headache occurrence is key to diagnosis

Associated complaints: trigeminal autonomic symptoms, such as nasal congestion and conjunctival injection

In addition, he becomes restless with the severe pain.

Diagnosis

This patient is experiencing cluster headaches, the most common type of trigeminal autonomic cephalgia.

Approach to treatment

If his examination is otherwise normal, his long history suggests that he does not need imaging.

If he did not have trigeminal cephalic changes, a blood test with erythrocyte sedimentation rate (ESR) would be warranted to evaluate this unilateral headache.

Historical exploration for other features of temporal arteritis is appropriate.

You could prescribe a tapering course of prednisone and sumatriptan injections for the exacerbation of headache. Alternatively, 100% oxygen could be used in place of the triptan injection. A prophylactic—before his seasonal clusters begin—is another strategy that you could discuss with him.