Headache diagnostic challenge

Diagnosing patient cases with headache symptoms

Headache clinical case 001

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

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.

Headache clinical case 002

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)

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).

Headache clinical case 003

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.

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.

This is an edited excerpt from the Medmastery course Headache Masterclass by Robert Coni, DO, EdS, FAAN. Acknowledgement and attribution to Medmastery for providing course transcripts.


Neurology Library: Headache – Treatment

Neurology Library

Robert Coni, DO, EdS, FAAN. Vascular neurologist and neurohospitalist and Neurology Subspecialty Coordinator at the Grand Strand Medical Center in South Carolina. Former neuroscience curriculum coordinator at St. Luke’s / Temple Medical School and fellow of the American Academy of Neurology. In my spare time, I like to play guitar and go fly fishing. | Medmastery | Linkedin |

BMBS (The University of Nottingham) BMedSci (The University of Nottingham). Emergency Medicine RMO at Sir Charles Gairdner Hospital Perth, WA. Interested in Medical Education and Emergency Medicine. Swimmer and frequent concert attendee.

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