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Headache is one of the most common painful conditions for which
patients consult physicians. Surveys indicate that in any given
year, more than 90% of American adults will suffer some
kind of headache or head pain.1 Fortunately, very
few headaches are caused by serious organic conditions, and most
headaches are actually migraine or tension-type headache. The first
step in treating a patient with headache is to establish an accurate
diagnosis, and for diagnostic purposes headaches are divided into
primary and secondary headache disorders. Secondary headaches have
an underlying cause, such as infection, eye disease, tumor, aneurysm,
meningitis, and so forth. Primary headache disorders are benign
and tend to recur. These headaches are caused by conditions for
which the true basis has not yet been established, but altered brain
serotonin chemistry clearly plays a role (see Chapter 19 for a discussion
of the biology of primary headaches). Chapter 17 outlines diagnostic
criteria for migraine, tension-type headache, and cluster headache,
the three most common headache syndromes. In this chapter, we comment
on differential diagnosis, diagnostic testing, and management of
patients with these common primary headache disorders.
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The two most common patterns of migraine are migraine with aura,
formerly called classic migraine, and migraine without aura, or
common migraine. Approximately 18% of women and 6% of
men in the United States are plagued by migraine, and 15% will
experience an aura with some of their migraine attacks.1
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Clinical Features
and Differential Diagnosis
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Blau has described five phases of migraine that are not universally
present and may variably occur during different attacks in the same
individual.2 The first phase, or prodrome, occurs
in 40% to 60% of migraineurs. It consists of altered
mood, irritability, depression or euphoria, fatigue, yawning, excessive
sleepiness, craving for chocolate, or other vegetative symptoms,
all of which suggest origin of these symptoms in the hypothalamus,
perhaps as a result of excessive dopamine stimulation. These symptoms
usually precede the headache phase of the migraine attack by several
hours or even days, and experience teaches the patient or observant
family that the migraine attack has begun.
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The second phase of migraine is the aura, consisting of either
visual or sensory phenomena (the two most common aura symptoms)
or motor weakness, incoordination, or dysphasic symptoms, such as
word-finding difficulty. The aura symptoms usually precede the headache
phase of the migraine attack, but occasionally occur simultaneously.
Sometimes, two aura symptoms occur in the attack, usually visual
and sensory symptoms that may occur simultaneously or consecutively. The
aura symptoms appear gradually over 5 to 20 minutes and usually
subside just before the headache begins.
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When examining a patient who has recently experienced only one
or two such attacks for the first time, the clinician must determine
whether these focal neurologic symptoms represent migrainous aura
or manifestations of transient ischemic attack (TIA) or even a focal
sensory seizure. Passage of time, ...