# Clinical Cases: Headache Disorders ## Case 1: Migraine with Aura ### Patient Presentation **Demographics:** 28-year-old female **Chief Complaint:** Recurrent severe headaches with visual disturbance for 5 years **History of Present Illness:** The patient describes episodic headaches occurring 3-4 times per month since age 23. A typical attack begins with a visual disturbance - she sees "zigzag shimmering lines" starting near the center of her vision, which gradually expand outward over about 20 minutes, leaving a temporary blind spot. About 10 minutes after the visual symptoms resolve, she develops a severe throbbing headache, usually on the right side. The headache is accompanied by nausea (she has vomited during several episodes), sensitivity to light, and sensitivity to sound. The pain is rated 8/10 and is worsened by physical activity like climbing stairs. Episodes last 12-24 hours if untreated. She retreats to a dark, quiet room during attacks. Her mother and sister also have migraines. **Current Episode:** - Visual symptoms began 45 minutes ago and have now resolved - Currently experiencing moderate right-sided pulsating headache with mild nausea - Prefers to keep lights dim in the examination room **Physical Examination:** - Vital signs: BP 118/72, HR 68, T 36.8C - General: Mild discomfort, photophobic (squints at lights) - Neurological examination: Completely normal including: - Mental status: Normal - Cranial nerves: Pupils reactive, extraocular movements intact, visual fields full, no papilledema - Motor: 5/5 throughout - Sensory: Intact - Reflexes: 2+ and symmetric - Gait: Normal **Red Flag Assessment:** - Not sudden onset ("thunderclap"): No - No neurological signs - No fever or neck stiffness - Pattern consistent with prior episodes - Age appropriate for migraine - No papilledema **Diagnosis:** Migraine with typical aura (visual) **Treatment:** *Acute Treatment:* - Sumatriptan 100 mg orally at headache onset - Metoclopramide 10 mg for nausea - Instructions to treat early for best efficacy *Preventive Treatment (indicated given >4 attacks/month):* - Topiramate 25 mg at bedtime, titrate to 50 mg twice daily over 6 weeks - Lifestyle modifications: regular sleep schedule, avoid identified triggers (patient notes stress and skipped meals trigger attacks) *Education:* - Keep headache diary to track frequency and triggers - Limit acute medication use to avoid medication overuse headache - Return if headache pattern changes **Clinical Course:** At 3-month follow-up, topiramate had reduced attack frequency to 1-2 per month. Sumatriptan effectively aborted most headaches when taken early. The patient reported improvement in quality of life with fewer missed workdays. **Clinical Pearl:** Migraine aura is a spreading cortical phenomenon (cortical spreading depression) that produces positive visual symptoms (scintillating scotoma with zigzag lines) that gradually expand over 5-60 minutes. This gradual spread distinguishes it from the sudden onset of stroke or TIA. The aura typically precedes the headache by minutes to an hour. Treatment with triptans is most effective when given during the aura or early headache phase before central sensitization develops. --- ## Case 2: Cluster Headache ### Patient Presentation **Demographics:** 42-year-old male **Chief Complaint:** Severe headaches around his right eye occurring nightly for 3 weeks **History of Present Illness:** For the past 3 weeks, the patient has been awakened from sleep almost every night between 2-3 AM by an excruciating pain centered around and behind his right eye. He describes the pain as "boring" and "like a hot poker in my eye." The pain reaches maximum intensity within 5 minutes and is rated 10/10 - the worst pain he has ever experienced. During attacks, his right eye becomes red and tears profusely, his right nostril runs, and he feels extremely restless - he cannot lie still and paces around his bedroom. Each episode lasts approximately 60-90 minutes then resolves completely. He has had 1-2 attacks per day, usually including one nocturnal attack and sometimes one in the late afternoon. He recalls having a similar "cluster" of headaches 2 years ago that lasted about 6 weeks and then resolved. **Observed During Attack in ED:** - Patient pacing, unable to sit still - Holding right side of head - Right eye: conjunctival injection (red), lacrimation (tearing), eyelid swelling - Right pupil: slightly smaller than left (miosis) - Right nostril: rhinorrhea **Physical Examination (between attacks):** - Vital signs: BP 132/82, HR 74, T 36.9C - General: Appears tired but comfortable - Neurological examination: Completely normal including pupils equal, no residual autonomic signs **Diagnosis:** Episodic cluster headache **Treatment:** *Acute Treatment:* - High-flow oxygen therapy: 100% O2 at 12-15 L/min via non-rebreather mask for 15-20 minutes at attack onset - Sumatriptan 6 mg subcutaneous injection (for attacks unresponsive to oxygen) *Transitional/Bridge Therapy:* - Prednisone 60 mg daily for 5 days, then taper over 2 weeks (rapid suppression of attacks while preventive takes effect) *Preventive Treatment:* - Verapamil 80 mg three times daily, titrate to 240 mg three times daily - ECG monitoring (verapamil can cause heart block at high doses) *Lifestyle:* - Avoid alcohol during cluster period (known trigger) - Maintain regular sleep schedule **Clinical Course:** Oxygen therapy aborted most attacks within 10-15 minutes. The prednisone burst rapidly reduced attack frequency. After verapamil reached therapeutic dose, attacks decreased to occasional mild episodes. The cluster period ended after 8 weeks total. The patient was educated about the likely recurrence in the future and maintained oxygen equipment at home. **Clinical Pearl:** Cluster headache is characterized by severe unilateral periorbital pain with ipsilateral autonomic features (conjunctival injection, lacrimation, nasal congestion/rhinorrhea, forehead sweating, miosis, ptosis, eyelid edema). Unlike migraine patients who lie still in dark rooms, cluster patients are agitated and restless during attacks. The attacks have remarkable periodicity - occurring at the same time daily, often awakening patients from sleep. High-flow oxygen is first-line abortive therapy and is effective in approximately 70% of patients within 15 minutes. --- ## Case 3: Thunderclap Headache - Subarachnoid Hemorrhage ### Patient Presentation **Demographics:** 48-year-old female **Chief Complaint:** "Worst headache of my life" sudden onset 2 hours ago **History of Present Illness:** The patient was exercising at the gym when she suddenly developed an extremely severe headache that reached maximum intensity within seconds. She describes it as "like being hit on the back of the head with a baseball bat." She immediately felt nauseated and vomited. The headache has persisted and remains severe. She has never had a headache like this before. She has mild neck stiffness. She has a history of hypertension and smokes half a pack of cigarettes daily. **Physical Examination:** - Vital signs: BP 178/102, HR 92, T 37.3C - General: In obvious distress, prefers to lie still with eyes closed - Neurological: - Mental status: Alert, oriented, following commands - Cranial nerves: Pupils equal and reactive; photophobic but eye movements intact - Motor: 5/5 throughout - Reflexes: 2+ symmetric - Neck: Nuchal rigidity (stiff neck; resistance to passive flexion) - Kernig and Brudzinski signs: Positive **Red Flag Assessment (SNOOP4):** - Sudden onset (thunderclap): YES - maximum severity within seconds - Neurological signs: Meningismus present - Older than usual migraine population: 48 years, no prior history - Pattern change: First ever headache of this severity **Workup:** - **CT head without contrast:** Hyperdensity in the basal cisterns, Sylvian fissures bilaterally, and interhemispheric fissure consistent with subarachnoid hemorrhage - **CT angiography:** 6 mm saccular aneurysm at the anterior communicating artery **Diagnosis:** Aneurysmal subarachnoid hemorrhage **Treatment:** - ICU admission - Blood pressure control (target SBP 120-140 to prevent rebleeding) - Nimodipine 60 mg every 4 hours for vasospasm prevention - Pain management - Neurosurgical/neurointerventional consultation - Endovascular coiling of aneurysm performed within 24 hours **Clinical Course:** Aneurysm was successfully coiled. The patient developed mild vasospasm on day 7 detected by transcranial Doppler, managed with hemodynamic augmentation. She was discharged on day 14 with minimal residual headache. At 3-month follow-up, she had returned to work with no significant deficits. **Clinical Pearl:** Thunderclap headache (maximum intensity within seconds to one minute) is a neurological emergency requiring immediate evaluation for subarachnoid hemorrhage. CT is highly sensitive (>95%) within 6 hours but sensitivity decreases over time. If CT is negative but clinical suspicion remains high, lumbar puncture is mandatory to look for xanthochromia and RBCs. Approximately 12% of patients presenting with thunderclap headache have SAH. The key teaching point: a sudden, severe, "worst ever" headache demands evaluation regardless of how well the patient looks. --- ## Clinical Image ![Migraine aura visual symptoms](case_01_image.jpg) **Image Description:** Illustration depicting the characteristic visual aura of migraine - a scintillating scotoma appearing as zigzag or fortification spectra lines (resembling castle battlements) that begin near central vision and gradually expand peripherally over 20-30 minutes. This cortical spreading depression moves across the visual cortex at approximately 3 mm per minute. **Attribution:** Image from Wikipedia (https://en.wikipedia.org/wiki/Scintillating_scotoma), Creative Commons license.