MKSAP Quiz: 4-year history of headaches
A 39-year-old woman is evaluated for a 4-year history of headaches that typically occur twice weekly and last 8 to 12 hours when not treated early. The pain is bilateral, frontotemporal, vice-like, and aggravated by physical activity. Following a physical and neurological exam, what is the most likely diagnosis?
A 39-year-old woman is evaluated for a 4-year history of headaches that typically occur twice weekly and last 8 to 12 hours when not treated early. The pain is bilateral, frontotemporal, vice-like, and aggravated by physical activity. Approximately half of the episodes have become severe and are associated with combined photophobia and phonophobia. She has had no associated nausea, vomiting, or visual or neurologic symptoms and reports no cranial autonomic features. Stress is the only clear trigger. Naproxen resolves the headache when administered early in the headache course. She takes no other medication.
On physical examination, vital signs are normal; BMI is 23. All other physical examination findings, including those from a neurologic examination, are unremarkable.
Which of the following is the most likely diagnosis?
A. Medication-overuse headache
B. Migraine
C. Sinus headache
D. Tension-type headache
MKSAP Answer and Critique
The correct answer is B. Migraine. This content is available to MKSAP 18 subscribers as Question 71 in the Neurology section. More information about MKSAP is available online.
The patient's headaches meet the diagnostic criteria for migraine. The International Classification of Headache Disorders (third edition [beta version]) (ICHD-3) criteria require at least five episodes lasting 4 to 72 hours when untreated (or unsuccessfully treated) for this diagnosis. Pain should exhibit two of the following four characteristics: unilateral location, throbbing nature, moderate to severe intensity, and worsening with physical activity. Associated features must include either nausea or a combination of photophobia and phonophobia. Neurologic symptoms reflective of aura are described by 30% of patients with migraine. There must be no evidence of a secondary pathologic cause of the headache. Patients with chronic migraine may report milder attacks meeting tension-type headache criteria with at least some attacks meeting full migraine criteria. This patient described 8- to 12-hour severe attacks aggravated by activity with associated combined photophobia and phonophobia; her neurologic examination findings are normal. Neuroimaging is unnecessary in typical migraine presentations such as hers.
Medication overuse headache may result from overtreatment with acute medication in patients with underlying migraine or tension-type headache. Use of triptans, ergot alkaloids, opioids, or combination analgesics for 10 or more days per month or simple analgesics for 15 or more days per month constitutes medication overuse. Naproxen sodium used 8 days per month does not constitute medication overuse.
Over 90% of self- and clinician-diagnosed “sinus” headaches fulfill criteria for migraine. Acute rhinosinusitis may cause discomfort in the head or face, but headache is late in the disease course and typically a minor feature. Correlation of chronic or recurrent headaches with sinonasal pathology is without solid evidence. Weekly episodes of headache without nasal or sinus symptoms have no origins in the sinus cavities.
Episodic tension-type headache (TTH) is characterized by attacks of a nondisabling headache that lacks the typical features of migraine. Episodes may last from 30 minutes to 1 week. The pain of TTH typically is not severe or aggravated by routine physical activity. Photophobia or phonophobia may be present, but not both, according to ICHD-3 criteria. Mild nausea sometimes is noted with chronic TTH (≥15 days/mo) but not episodic TTH (<15 days/mo). Moderate to severe nausea and aura are not found with either TTH subtype.
Key Point
- The diagnosis of migraine requires at least five episodes lasting 4 to 72 hours when untreated (or unsuccessfully treated), with pain exhibiting two of the following characteristics: unilateral location, throbbing nature, moderate to severe intensity, and worsening with physical activity; associated features must include either nausea or a combination of photophobia and phonophobia.