Skill Checkup: A 20-Year-Old Woman With a Diffuse Pulsatile Headache, Neck Pain, and Nausea

Helmi L. Lutsep, MD


February 10, 2022

Although the diagnosis of migraine is a clinical one, the workup approach may be geared toward ruling out other conditions, depending on patient presentation. Because the patient describes the current episode as "the worst headache of her life," this red flag may inform diagnostic testing. Neuroimaging is indicated if the patient presents with their first or most severe headache; a change is seen in the previous migraine pattern; the patient has an abnormal neurologic examination; onset of migraine occurs after age 50 years; new onset of headache is seen in an immunocompromised patient; headache is accompanied by fever; migraine is seen with epilepsy; new daily, persistent headache develops; headache is posterior (especially in children); and escalation of headache frequency/intensity in the absence of medication overuse headache. Of note, the American Headache Society recommends that neuroimaging studies are not necessary in patients with recurrent headaches that meet criteria for migraine, and that CT should not be performed for headache when MRI is available.

In general, migraine is diagnosed on the basis of patient history. The American Headache Society defines migraine as when a patient reports at least five attacks. These episodes must last 4-72 hours and have at least two of these four characteristics: unilateral location, pulsating quality, moderate or severe pain intensity, and aggravation by or causing avoidance of routine physical activity. In addition, the patient must experience either nausea and/or vomiting or photophobia and phonophobia during attacks. Lastly, these signs and symptoms cannot be accounted for by another diagnosis.

Indications for lumbar puncture overlap with those of neuroimaging, but this approach should precede lumbar puncture in the flow of workup to rule out a mass lesion and/or increased intracranial pressure. Lumbar puncture indications include severe, rapid-onset, recurrent headache; the patient presents with their first or most severe headache; progressive headache; and chronic unresponsive headache.


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