Oh by the way. . .what about my headaches?

Caroline is a 23-year-old college student in for her annual exam. A nonsmoker with normal blood pressure, she has normal body weight and no health problems. She's been taking a 30-μg estrogen oral contraceptive (OC) for the last 3 years, and as she's walking out the door with a new prescription in hand, turns to you and says, "Oh, by the way...can you give me something for my headaches?"

Sixty to 80% of adults report having experienced an episodic headache in the last year. The most common types are tension headaches and migraines, and women are more likely than men to be sufferers. Six percent of men report having migraines, compared with 18% of women. Migraines in women are most common during the reproductive years, suggesting a hormonal relationship.

In our experience with adolescents and young adults, and with patients of older reproductive age, many woman have severe headaches that can be classified as migraines-whether associated with menstruation or not-but few of them have been given that specific diagnosis by a physician. No clinician wants to misdiagnose a brain tumor that presents with headaches, but most women who complain of head pain will be found to have tension-type or migraine headaches.

Most headaches can be diagnosed on the basis of clinical symptoms. The one description of a headache that requires a thorough evaluation for unusual neurologic causes is the new-onset headache that an adult says is "the worst headache in my life." That presentation is unusual and it always prompts us to refer for a neurologic evaluation. The presence of severe and complicated neurologic symptoms during or before a headache should also cause you to consider referral.

The typical migraine is a severe, throbbing headache that is not helped by pain medications such as acetylsalicylic acid and acetaminophen but for which a dark room and sleep provide relief. According to the International Classification of Headaches, migraine without aura must have at least two of the following four characteristics: unilateral location; pulsating quality; moderate or severe pain intensity; or aggravation by physical activity. It is also associated with at least one of the following: (1) nausea and/or vomiting; or (2) photophobia and/or phonophobia.

Migraine is sometimes preceded by an aura, or transient and fully reversible visual or physical symptoms that occur within an hour of the onset of headache.^1,2 But what visual symptoms constitute aura? According to the British Association for the Study of Headache, visual blurring and "spots" are not diagnostic of aura.³ Migraine without aura can be pulsating and associated with nausea, vomiting, photophobia, or phonophobia, symptoms that at first give the wrong impression. Visual symptoms of aura usually precede a headache and include areas of lost or depressed vision, scintillating scotomata or bright, jagged lines through the field of vision, possibly in association with paresthesias and/or dysphasia. Other phenomena that may precede migraine include loss of vision, a transient "pins and needles" sensation or numbness, and dysphasia.

Migraine symptoms require careful questioning to elicit accurate descriptions. Ask if the patient has ever had a "warning" that she was going to get a severe headache, and probe for "changes in your vision, bright flashing lights/lightning/zigzags/or fireworks or loss of vision." You should also ask if she's ever had a "numbness, tingling, or pins and needles" feelings before a headache, how long it lasted, and how soon after the symptoms the headache began.

In taking a headache history, we typically ask the following questions:
1. How does your headache start? (See previous probes for aura.)
2. Where does your head hurt? (frontal, occipital, uni- or bilateral)
3. What is the pain like? (steady or throbbing)
4. Do you have any symptoms other than pain? (photo- or phonophobia, nausea/vomiting)
5. On a scale of 1 to 10, how bad is the pain?
6. What have you tried to relieve your symptoms and what, if anything, works?