Case Study 3: Frequent Migraines

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Headshot of Dawn Elise DeWitt, MD, MSc, CMedEd, MACP, FRACP, FRCP-London · Senior Associate Dean, Collaboration for InterProfessional Health Education Research & Scholarship (CIPHERS)
Dawn Elise DeWitt
MD, MSc, CMedEd, MACP, FRACP, FRCP-London · Senior Associate Dean, Collaboration for InterProfessional Health Education Research & Scholarship (CIPHERS)
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Case study 3: Jody—Frequent migraines

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Today’s patient is a 30-year-old grocery clerk who is visiting the clinic to discuss management of her increasingly frequent migraines. She reports an 18-year history of migraines with interval headaches. Her mother and brother also have migraines. She says she is usually sensitive to light before and during her migraine, but denies nausea, vomiting, and sensitivity to noise.
Prior to the past few months, she would only get migraines a few times per month; she now endorses having migraines almost every other day (14 total last month), which tend to be present upon waking. She says she is also now “seeing flashes of light” before her migraines. The patient denies any other new systemic symptom, and says that nothing has changed as far as her work situation, diet, or sleep schedule. She has no new life stressors. As a result of the increased frequency of migraines, she has been using more OTC pain medication as well as sumatriptan tablets, and would like to know if you can increase the dosage of her sumatriptan or add another medication.
She also expresses concern about the drastic increase in her number of monthly migraines, and wonders if there might be “something else going on.”

Question

Which of the following is the most appropriate test to order today?

Brain MRI:

  • At this point, a brain MRI is warranted to rule out secondary causes of the patient’s migraine. An insidious, progressive worsening of migraine headaches could reflect a number of processes. High on the differential would be a brain tumor or other mass lesion, chronic subdural hematoma, or one of many causes of increased ICP. Migraines caused by untreated sleep apnea can also have a predilection for morning presentation and could certainly be a consideration as well. 

Non-contrast CT:

  • A non-contrast head CT is typically warranted in the case of a suspected acute brain bleed, or to rule out hemorrhage in the setting of suspected stroke. Neither of these would be high on the differential for this patient, who lacks localizing focal neurologic deficits (facial droop, slurred speech, extremity weakness) and whose symptoms have taken an insidiously progressive course (months). In this case, it would be more efficient and informative to get an MRI.

Lumbar puncture:

  • A lumbar puncture could certainly be helpful in determining the cause of chronic, progressive migraines—if, for example, elevated opening pressure was noted, that might be indicative of something like pseudotumor cerebri. However, it would not be first-line in this situation. Right now, it is more critical to rule out something like a chronic subdural hematoma or mass-occupying lesion, which cannot be done via LP.

EEG:

  • While an EEG can be helpful in determining possible seizure activity, it is not particularly useful in the setting of severe headaches or migraines that lack localizing focal neurologic deficits.

Question

Which of the following aspects of her history is most suggestive of a secondary headache cause?

Increasing frequency of migraine (correct answer):

  • An increased frequency of migraines does qualify this patient for additional workup to rule out secondary causes of her pain. She is reporting a fairly drastic increase in the number of migraines she has each month, and has also developed what is probably an aura (“flashing lights”). Any time there is a worsening of an underlying primary headache disorder, it is necessary to rule out a secondary process. 

Family history of migraines:

  • Many migraineurs report a family history of migraines, similar to this patient. This does not raise suspicion of a secondary cause of her migraines, and it also does not reduce suspicion. There is nothing stopping a migraine patient from developing a brain tumor, bleed, or elevated ICP, amongst other causes of apparently worsening symptoms.  

Seeing “flashing lights” before her migraine:

  • Visual phenomena such as “flashing lights,” scotomata, and scintillations are very common findings in migraine aura. This symptom would not in and of itself raise concern for a secondary headache.

Lack of associated nausea or vomiting:

  • This is not concerning whatsoever; while many patients do experience nausea and vomiting as part of their migraines, it is certainly not a diagnostic parameter.

 

  Keywords: Headache, migraine, treatment

Note

Distinguish between progression of migraine to daily headache and secondary causes of headache through testing.

References

  1. Rizzoli, P. MD, FAHS and Mullally, W. MD, FAHS. Headache. American Journal of Medicine, vol. 131, No. 1, Jan. 2018.
  2. Wootton, R.J., Wippold II, F.J. Evaluation of headache in adults. In:UpToDate. Updated Aug. 12, 2021.
  3. Clinch, Randall, D.O. Evaluation of Acute Headache in Adults. Am Fam Physician. 2001 Feb 15;63(4):685–693.
  4. Suzuki K, Miyamoto M, Miyamoto T, et al. Sleep apnoea headache in obstructive sleep apnoea syndrome patients presenting with morning headache: comparison of the ICHD-2 and ICHD-3 beta criteria. J Headache Pain. 2015;16:56. doi:10.1186/s10194-015-0540-6.

Image credits

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