# Clinical Cases: Headache Disorders

## Case 1: Migraine with Aura

### Patient Demographics
- **Age:** 28 years
- **Sex:** Female
- **Occupation:** Graphic designer

### Chief Complaint
"I see zigzag lines before I get a terrible headache."

### History of Present Illness
The patient reports episodic severe headaches occurring 3-4 times per month for the past 5 years. Each episode begins with visual disturbances - she sees "shimmering zigzag lines" that start in her central vision and expand peripherally over 20-30 minutes. As the visual symptoms resolve, she develops a unilateral throbbing headache (alternating sides), usually rated 8/10 in severity. Associated symptoms include nausea, occasional vomiting, photophobia, and phonophobia. Episodes last 12-24 hours and are partially relieved by lying in a dark, quiet room. She notes headaches are more frequent around her menstrual period and triggered by stress and lack of sleep.

### Neurological Examination Findings

**Mental Status:**
- Alert, oriented, appropriate (examined between attacks)

**Cranial Nerves:**
- Visual acuity: 20/20 bilateral
- Visual fields: Full to confrontation
- Pupils: Equal, round, reactive
- Extraocular movements: Intact, no nystagmus
- Face symmetric, sensation intact

**Motor Examination:**
- 5/5 strength throughout
- Normal tone and bulk

**Sensory Examination:**
- Intact to light touch, pinprick, vibration, and proprioception

**Reflexes:**
- 2+ symmetric throughout
- Plantar responses flexor bilaterally

**Coordination:**
- Finger-to-nose and heel-to-shin normal
- No tremor

**Gait:**
- Normal, tandem intact

### Diagnostic Criteria Applied
**ICHD-3 Criteria for Migraine with Aura:**
- At least 2 attacks fulfilling criteria B-D
- One or more fully reversible aura symptoms (visual - YES)
- At least 3 of: spreads gradually over ≥5 min (YES), symptoms last 5-60 min (YES), at least one symptom is unilateral (YES), aura accompanied by headache within 60 min (YES)
- Not better accounted for by another diagnosis

### Neuro Workup
- **Neurological examination:** Normal between attacks - no further imaging required per guidelines
- **MRI Brain (obtained for reassurance):** Normal, no white matter lesions
- **This patient does NOT have red flags:**
  - No thunderclap onset
  - No fever
  - No new neurological deficits
  - No papilledema
  - No change in established headache pattern

### Diagnosis
**Migraine with typical visual aura (episodic)** - high frequency (approaching chronic migraine threshold)

### Management

**Acute Treatment:**
1. Sumatriptan 100 mg PO at aura onset or early headache
2. Naproxen 500 mg as adjunct or alternative
3. Metoclopramide 10 mg for nausea
4. Limit acute medication use to <10 days/month to prevent medication overuse headache

**Preventive Treatment (indicated: ≥4 headache days/month):**
1. First-line: Topiramate 25 mg, titrate to 50-100 mg BID
2. Alternatives: Propranolol, amitriptyline, or valproate
3. Consider CGRP monoclonal antibody (erenumab, fremanezumab) if refractory

**Lifestyle Modifications:**
1. Regular sleep schedule (7-8 hours)
2. Stress management
3. Regular meals (avoid fasting)
4. Headache diary to identify triggers
5. Aerobic exercise 30 min, 3x/week

**Menstrual Migraine Prophylaxis:**
1. Perimenstrual naproxen 500 mg BID starting 2 days before expected menses
2. Or frovatriptan 2.5 mg BID perimenstrually

### Clinical Image
![Migraine Visual Aura](case_01_image.jpg)

**Image Description:** Artistic representation of a scintillating scotoma (fortification spectra), the classic visual aura of migraine, showing zigzag lines expanding from central vision.

**Attribution:** Image from Wikipedia Commons, by Bowmans_capsule. Licensed under CC BY-SA 4.0. Source: https://commons.wikimedia.org/wiki/File:Migraine_aura.jpg

---

## Case 2: Cluster Headache

### Patient Demographics
- **Age:** 35 years
- **Sex:** Male
- **Occupation:** Electrician

### Chief Complaint
"I get the worst pain of my life behind my right eye - it makes me want to bang my head against the wall."

### History of Present Illness
For the past 3 weeks, the patient has been experiencing excruciating headaches centered around his right eye. The pain comes suddenly, reaching peak intensity within 5-10 minutes, and lasts 45-90 minutes. During attacks, his right eye becomes red and teary, his right nostril is congested then runny, and his right eyelid droops. The attacks occur 2-3 times daily, often waking him from sleep at the same time each night (around 2 AM). He is unable to lie still during attacks - he paces, rocks, or hits his head. He denies nausea but cannot eat during attacks due to severity. He experienced similar episodes last spring that lasted 6 weeks then completely resolved.

### Neurological Examination Findings

**Between Attacks:**
- Mental status: Normal
- Cranial nerves: II-XII intact, no ptosis currently
- Motor: 5/5 throughout
- Sensory: Intact
- Reflexes: 2+ symmetric
- Coordination and gait: Normal

**During Attack (observed in ED):**
- Severe agitation, unable to sit still, pacing
- Right eye: Conjunctival injection, lacrimation
- Right nostril: Clear rhinorrhea
- Right eyelid: Partial ptosis
- Right pupil: Slightly miotic compared to left
- Patient rating pain 10/10

### Diagnostic Criteria Applied
**ICHD-3 Criteria for Cluster Headache:**
- At least 5 attacks fulfilling criteria B-D (YES)
- Severe unilateral orbital/supraorbital/temporal pain lasting 15-180 min (YES - 45-90 min)
- Either or both: ipsilateral autonomic symptoms (YES - all present) or restlessness/agitation (YES)
- Attack frequency: 1 to 8 per day (YES - 2-3/day)
- Not better accounted for by another diagnosis

**Episodic vs Chronic:** Episodic (remission periods of ≥3 months)

### Neuro Workup
- **MRI Brain with and without contrast:** Normal, no pituitary lesion
- **MRA Head:** No aneurysm or vascular abnormality
- **Imaging indicated:** First cluster presentation to exclude secondary causes (pituitary tumor, cavernous sinus lesion, arterial dissection)

### Diagnosis
**Episodic cluster headache** (right-sided)

### Management

**Acute Treatment:**
1. **First-line:** High-flow oxygen 100% via non-rebreather mask at 12-15 L/min for 15-20 minutes (keep at home)
2. **First-line:** Sumatriptan 6 mg subcutaneous injection (maximum 2/day)
3. **Alternative:** Zolmitriptan 5 mg nasal spray
4. Avoid oral triptans (too slow onset)

**Transitional Prophylaxis (Bridge Therapy):**
1. Prednisone 60-80 mg daily for 5 days, then taper over 2-3 weeks
2. Or occipital nerve block (greater occipital nerve)

**Preventive Treatment (for cluster period):**
1. Verapamil 80 mg TID, titrate to 240-480 mg/day (monitor ECG for heart block)
2. Alternatives: Lithium, topiramate, melatonin

**Lifestyle:**
1. Avoid alcohol during cluster period (potent trigger)
2. Avoid afternoon naps
3. Maintain regular sleep schedule
4. No smoking (theoretical trigger)

### Clinical Image
![Cluster Headache Features](case_02_image.jpg)

**Image Description:** Clinical photograph demonstrating the autonomic features of cluster headache during an attack: conjunctival injection, lacrimation, and partial ptosis of the right eye.

**Attribution:** Image from Wikipedia Commons, public domain. Source: https://commons.wikimedia.org/wiki/File:Cluster_headache.jpg

---

## Case 3: Secondary Headache - Idiopathic Intracranial Hypertension

### Patient Demographics
- **Age:** 32 years
- **Sex:** Female
- **Occupation:** Administrative assistant
- **BMI:** 38 kg/m²

### Chief Complaint
"My headaches are getting worse and sometimes my vision goes gray."

### History of Present Illness
The patient reports progressive daily headaches over the past 4 months. The headache is generalized, pressure-like, worse in the morning and with bending over, coughing, or straining. She hears a "whooshing" sound in her ears that pulses with her heartbeat (pulsatile tinnitus). She has transient visual obscurations - brief episodes lasting seconds where her vision "grays out," especially when standing up or bending. She has noticed peripheral vision loss and intermittent horizontal diplopia. She gained 30 lbs over the past year. Recent medications include oral contraceptive pills.

### Neurological Examination Findings

**Mental Status:**
- Alert, oriented, appropriate

**Cranial Nerves:**
- Visual acuity: 20/25 right, 20/30 left
- **Fundoscopy: Bilateral papilledema (Grade II) - blurred disc margins, obscuration of vessels**
- Visual fields: Enlarged blind spots bilaterally, inferonasal field constriction
- Pupils: Normal reactivity
- **Left CN VI palsy** - esotropia in primary gaze, cannot abduct left eye (false localizing sign of increased ICP)
- Other CNs intact

**Motor Examination:**
- 5/5 strength throughout

**Sensory Examination:**
- Intact

**Reflexes:**
- 2+ symmetric

**Coordination and Gait:**
- Normal

### Diagnostic Criteria Applied
**Modified Dandy Criteria for IIH:**
1. Signs/symptoms of increased ICP (YES - headache, papilledema, pulsatile tinnitus, visual obscurations, VI palsy)
2. No localizing neurological signs except VI palsy (YES)
3. CSF opening pressure ≥25 cm H2O (YES - see below)
4. Normal CSF composition (YES)
5. No other identifiable cause of intracranial hypertension (YES - imaging negative)

### Neuro Workup
- **MRI Brain with and without contrast:** Normal brain parenchyma; findings of IIH: flattening of posterior sclera, empty sella, distension of optic nerve sheath, stenosis of transverse venous sinuses
- **MRV:** Patent venous sinuses, no thrombosis
- **Lumbar puncture (lateral decubitus):**
  - Opening pressure: 32 cm H2O (elevated; normal <25)
  - CSF clear, colorless
  - WBC 1, protein 22, glucose 65 (normal composition)
  - Patient reports headache improvement after LP
- **Formal perimetry (Humphrey visual field):** Enlarged blind spots, inferior nasal field defects

### Diagnosis
**Idiopathic Intracranial Hypertension (IIH)** / Pseudotumor cerebri

### Management

**Acute Management:**
1. Large-volume LP (therapeutic) performed - 20 mL removed

**Medical Treatment:**
1. Acetazolamide 500 mg BID, titrate to 1-2 g/day (max 4 g/day)
   - Monitor electrolytes for metabolic acidosis and hypokalemia
2. Potassium supplementation as needed
3. Topiramate 25-100 mg BID (also promotes weight loss)

**Weight Management (most important long-term):**
1. Target weight loss of 5-10% body weight
2. Dietary counseling, low-sodium diet
3. Consider bariatric surgery referral if medical weight loss fails

**Ophthalmological Follow-up:**
1. Serial visual field testing every 4-6 weeks initially
2. OCT for retinal nerve fiber layer thickness
3. Monthly fundoscopic examinations

**Interventional Options (if failing medical therapy):**
1. Serial therapeutic LPs (bridge until medications work)
2. Optic nerve sheath fenestration (if vision threatened)
3. VP or LP shunt (for intractable headache)
4. Venous sinus stenting (if significant stenosis)

**Medication Adjustments:**
1. Discontinue oral contraceptives (possible contributor)

### Clinical Image
![Papilledema](case_03_image.jpg)

**Image Description:** Fundoscopic photograph showing bilateral papilledema with blurred optic disc margins, elevated disc, and obscuration of vessels at the disc margin.

**Attribution:** Image from Wikipedia Commons, by Jonathan Trobe, M.D. Licensed under CC BY 3.0. Source: https://commons.wikimedia.org/wiki/File:Papilledema.jpg