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Half title
Title
Copyright
Dedication
Contents
Preface
Acknowledgements
1 Confusing one benign headache with another
Migraine or tension-type headache?
Case
How can migraine be reliably distinguished from tension-type headache in this patient?
What benign headache disorder might account for this patient’s headaches?
Discussion
Diagnosis
Tip
Migraine with or without aura?
Case
What important piece of information is still missing in this case?
Does this patient have migraine with aura?
Are estrogen-containing contraceptives contraindicated in women who have migraine with aura?
Discussion
Diagnosis
Tip
Severe unilateral headaches in a man
Case
Is this history consistent with a diagnosis of cluster headache?
Why was the diagnosis of migraine missed in this patient?
Discussion
Diagnosis
Tip
Frequent, severe episodic headaches in a woman
Case
Has this patient developed chronic migraine?
Why was cluster headache misdiagnosed in this patient?
Discussion
Diagnosis
Tip
Headache with disturbing visual perceptual alterations
Case
What conditions may be causing these symptoms?
How should this patient be treated?
Discussion
Diagnosis
Tip
“Cluster migraine”
Case
Are this patient’s autonomic features helpful in making a diagnosis?
Is “cluster migraine” an appropriate diagnosis in this patient?
Discussion
Diagnosis
Tip
Stabbing headaches in a migraineur
Case
What is the differential diagnosis of sharp, stabbing pain in a migraineur?
Does any further workup need to be done for this new headache type?
Discussion
Diagnosis
Tip
Chronic continuous headache with acute onset
Case
What is the differential diagnosis in this case?
What advice can be provided to the patient about the natural history of NDPH, and is any further workup required?
Discussion
Diagnosis
Tip
Strictly unilateral headache
Case
What additional question might clarify the diagnosis in this case?
What treatment should be tried next?
Discussion
Diagnosis
Tip
2 Mistaking primary headache for another condition
“Sinus headache”
Case
How is chronic sinus disease diagnosed?
Won’t imaging clarify the diagnosis of sinusitis?
What sinus-related headaches do headache specialists recognize?
Discussion
Diagnosis
Tip
Chronic headache after Lyme disease
Case
How common is headache in patients with Lyme disease and is it likely that this patient’s headaches were due to persistent neurologic infection?
What are the symptoms of chronic Lyme neuroborreliosis and how is it treated?
Discussion
Diagnosis
Tip
Headache in the setting of temporomandibular abnormalities
Case
How likely is this daily headache to be due to pathology of the TMD?
Discussion
Diagnosis
Tip
Postpartum headache
Case
What is the differential diagnosis of postpartum headache?
Should further diagnostic testing be done? If so, what?
Discussion
Diagnosis
Tip
A middle-aged man with low-lying cerebellar tonsils
Case
How can headache attributed to a Chiari I malformation be diagnosed?
What treatment should be recommended to this patient?
Discussion
Diagnosis
Tip
Cluster headache presenting as a dental problem
Case
What is the most likely diagnosis in this case?
Was the dental work this patient had indicated?
Discussion
Diagnosis
Tip
An older woman with focal neurologic deficits but no headache
Case
This patient had a negative workup a month ago. Should she be reinvestigated now or could this be a benign process?
What is the epidemiology of late-life migraine accompaniments, and should they be treated?
Discussion
Diagnosis
Tip
Prolonged aura
Case
What is the likely diagnosis in this case?
What is the differential diagnosis of prolonged aura?
Discussion
Diagnosis
Tip
A middle-aged woman with vertigo and a history of migraine
Case
Could this patient’s vertigo be migrainous in origin?
What treatments are available to this patient?
Discussion
Diagnosis
Tip
3 Missing dangerous causes of headache
New headache in an elderly woman
Case
What are the leading diagnostic possibilities and how would you proceed in evaluating them?
Why was the correct diagnosis delayed?
Discussion
Diagnosis
Tip
A young man with head pain, nausea, and fever
Case
Does this sound like migraine?
What is the next step in management?
What is the nociceptive innervation of the paranasal sinuses?
Discussion
Diagnosis
Tip
Weekend headache
Case
Based on this patient’s clinical presentation, what are some diagnostic considerations?
Does the additional history change your mind about possible diagnoses?
Discussion
Diagnosis
Tip
A young woman with seizure and headache
Case
What is the relationship between seizures and headaches?
What treatment options are available?
Discussion
Diagnosis
Tip
Intermittent red eye and headache
Case
What are the possible causes of intermittent red eye and headache?
What is the next step in evaluation of this patient?
Discussion
Diagnosis
Tip
A young woman with morning headaches
Case
Is it appropriate to order imaging in this case?
This seemed like a benign headache. What was missed?
Discussion
Diagnosis
Tip
More morning headaches
Case
What are possible diagnoses for this headache presentation and what testing would you consider?
Discussion
Diagnosis
Tip
A middle-aged man with side-locked headache
Case
Should the patient initially have been advised that the MRI finding was unrelated to the headache pattern?
What are the characteristics of headaches in people with pituitary tumors?
Discussion
Diagnosis
Tip
Fatal migraine
Case
Can migraine be lethal?
How might migraine aura lead to stroke?
Discussion
Diagnosis
Tip
Severe headache in a new mother
Case
Would you give this patient sumatriptan?
Could this be something other than migraine?
Discussion
Diagnosis
Tip
4 Pitfalls in diagnostic testing: imaging and lumbar puncture
Refractory migraine in the emergency department
Case
What additional testing is needed?
Can the radiation risks of a single head CT be quantified?
Discussion
Diagnosis
Tip
A young woman with stable headaches
Case
Were there medical reasons to scan this patient?
Does testing reassure patients?
When diagnostic imaging is indicated, should patients be warned of the possibility of incidental findings?
Discussion
Diagnosis
Tip
A young man with constant headaches
Case
Were there medical reasons to scan this patient?
How do you reconcile this finding with the fact that neuroimaging is not recommended in cases of stable headache that meet criteria for migraine?
Should an event like this change your practice? Since it is never possible to be certain a patient doesn’t have something seriously wrong, shouldn’t we image everyone with headache?
Discussion
Diagnosis
Tip
Severe, sudden headache while mowing the lawn
Case
What is the clinical term used to describe the sudden onset of extremely severe headache, and what is the differential diagnosis?
What workup should she have?
Discussion
Diagnosis
Tip
Incidental white matter lesions in a migraineur
Case
What is known about white matter lesions in people with migraine?
Is any further workup or treatment required?
Discussion
Diagnosis
Tip
Familial occurrence of white matter lesions
Case
What is the differential diagnosis of this pattern of white matter abnormalities?
What is the next step?
Discussion
Diagnosis
Tip
A young man with headache following lumbar puncture
Case
Did this patient need neuroimaging or additional testing?
Since the epidural blood patch was only temporarily successful, should this patient be treated with an epidural saline infusion or intravenous caffeine?
Discussion
Diagnosis
Tip
A college student with malaise and a change in headache pattern
Case
When should a lumbar puncture be performed for the evaluation of headache?
Was the hesitance to perform a lumbar puncture in this patient warranted?
Discussion
Diagnosis
Tip
Optimizing the performance of lumbar puncture
Case
How do you advise the resident?
Procedure
Are there guidelines for the performance of lumbar puncture?
Misinterpreting the workup in low CSF pressure headache
Case
Is cervicogenic headache the best diagnosis in this patient?
What features of the history are of most value in establishing the correct diagnosis in this case?
Discussion
Diagnosis
Tip
5 Pitfalls in diagnostic testing: blood, urine, and other tests
Hormone testing in women with menstrual headaches
Case
What is the patient describing and how can that diagnosis be confirmed?
Is it useful to check hormone levels in women who have menstrual migraine?
Discussion
Diagnosis
Tip
Monitoring verapamil treatment in cluster headache
Case
Should this patient’s verapamil prescription be refilled?
How common are electrocardiographic abnormalities with verapamil treatment for cluster headache?
Discussion
Diagnosis
Tip
Urine drug testing in patients taking opioids
Case
What are the possible explanations for these urine findings?
How else might this patient’s use of fentanyl be monitored?
Discussion
Diagnosis
Tip
Lithium levels in a patient with cluster headache
Case
What are the possible explanations for this patient’s lithium level?
How common is nonadherence to drug therapy in headache patients and why does it occur?
Discussion
Diagnosis
Tip
A young man with body aches, rash, and headache
Case
Can headache be a symptom of HIV infection?
What are some other possible causes of headache in people with HIV infection?
Discussion
Diagnosis
Tip
A young woman with headache and multiple laboratory abnormalities
Case
Was it a mistake to order all of these tests?
Discussion
Diagnosis
Tip
6 When historical or examination findings are missed or misinterpreted
A young man with visual changes and a sore head
Case
What is the differential diagnosis of these visual symptoms?
What bedside test may have helped clarify the diagnosis?
Discussion
Diagnosis
Tip
A young woman with a headache that was “worse than ever”
Case
Was the physician’s level of concern appropriate?
Two evaluations of the same historical information produced divergent outcomes. What went wrong?
Discussion
Diagnosis
Tip
Intractable headache and psychiatric illness in a young woman
Case
Should the patient’s doctors have suspected a prior history of abuse or trauma?
How and when should questions about abuse or trauma be asked?
How should doctors respond when patients disclose abuse or trauma?
Discussion
Diagnosis
Tip
A man with headache, neurologic symptoms, and spinal fluid pleocytosis
Case
Was a diagnosis of encephalitis appropriate in this case?
What is the best diagnosis at this point?
In hindsight, what historical and examination features might have suggested this patient’s condition was benign?
Discussion
Diagnosis
Tip
An elderly woman with giant cell arteritis and persistent headache on steroids
Case
Was giant cell arteritis the best initial explanation of the headache pattern?
When should a diagnosis be reconsidered?
Discussion
Diagnosis
Tip
A man with unilateral headache and subtle eye findings
Case
What is the differential diagnosis, and what tests should be performed next?
What is the cause of the physical examination findings in this patient?
What accounts for the diagnostic “near miss” in this case and how can mistakes like this be avoided?
Discussion
Diagnosis
Tip
An older woman with focal headache
Case
What is the differential diagnosis?
What laboratory or other investigation should this patient have?
How should this patient’s herpes zoster be treated?
Discussion
Diagnosis
Tip
A 27-year-old woman with weakness and headache
Case
What were the diagnostic possibilities based on the history?
What historical and physical examination findings were at odds with the diagnosis of hemiplegic migraine?
How does the management of migraine with typical aura differ from that of hemiplegic migraine?
Discussion
Diagnosis
Tip
7 Errors in management of acute headache
A migraineur who does not respond to triptan treatment
Case
Why should NSAIDs be avoided after bariatric surgery?
What are the possible explanations for this patient’s failure to respond to triptans?
Discussion
Diagnosis
Tip
A young woman with chest pressure from sumatriptan
Case
Were the electrocardiogram and cardiovascular investigation indicated?
Should this patient be advised to avoid triptans?
Discussion
Diagnosis
Tip
Worries about serotonin syndrome
Case
Were the physician’s treatment recommendations appropriate?
Is there anything that the provider could have done differently to avoid the patient leaving care?
Discussion
Diagnosis
Tip
A patient with sulfa allergy and migraine
Case
Should the patient be switched to a different medication?
Discussion
Diagnosis
Tip
Adverse effects associated with regular long-term NSAID use
Case
How would you advise this patient, and is any further evaluation indicated?
What treatment options are available for this patient’s headaches, and what could have been done to prevent her kidney problems?
Discussion
Diagnosis
Tip
Agitation after intravenous treatment for acute headache
Case
Given the clinical description provided, what is the likely cause of this patient’s symptoms? Was the additional prochlorperazine a good idea?
How should this patient’s symptoms be treated? Can neuroleptic-induced extra-pyramidal symptoms be prevented?
Discussion
Diagnosis
Tip
A woman with intractable headache and vomiting
Case
When should someone with a bad headache go to the emergency department?
What strategy might be helpful in treating this headache, and prevent similar situations in the future?
Discussion
Diagnosis
Tip
A never-ending migraine
Case
What is this patient’s diagnosis and how should it be treated?
How could migraine recurrence and return to the ED have been prevented?
Discussion
Diagnosis
Tip
A man with cluster headache and limited sumatriptan access
Case
Was this patient receiving optimal treatment for individual attacks of headache?
How does oxygen work to abort an attack of cluster headache?
Discussion
Diagnosis
Tip
A woman with migraine planning to attempt pregnancy
Case
What options are available for treating her migraines during pregnancy?
Can she take sumatriptan?
Discussion
Diagnosis
Tip
Treatment of headache during lactation
Case
How is medication safety during lactation determined?
What medications can be recommended to treat this patient’s headaches while she is breast-feeding?
Discussion
Diagnosis
Tip
8 Pitfalls in drug therapy to prevent headaches
A man with frequent headaches who does not want daily medicine
Case
Was the physician right to urge the use of preventive medication for migraine?
Is daily medication the only thing that might reduce the risk of chronic migraine for this patient?
Discussion
Diagnosis
Tip
Selecting preventive treatment for a patient who has never used it
Case
What does this patient’s clinical course suggest and what treatment would you recommend?
What are the choices for preventive treatment of migraine, and how do you choose among them?
Which preventive medications are less likely to produce weight gain or other undesirable side effects?
Discussion
Diagnosis
Tip
Preventive treatment for a patient who has “tried everything”
Case
Do you agree that this patient is refractory to commonly used migraine preventive medications?
How could the need for retrials of medication have been prevented?
Discussion
Diagnosis
Tip
Another patient who has tried everything
Case
Has this patient tried everything, and should she quit her job?
How firm is the evidence supporting the use of combinations of preventive treatments for headache?
Discussion
Diagnosis
Tip
Preventive treatment in a patient with multiple medical conditions
Case
Are the patient’s new medications or her elevated blood pressure producing headache?
How do the patient’s comorbid conditions affect the choice of treatment for her migraines?
Discussion
Diagnosis
Tip
A woman on migraine prophylaxis who wants to become pregnant
Case
What is known about the effect of pregnancy on migraine, and does migraine increase the risk of poor pregnancy outcomes?
What options are available for preventive treatment of migraine during pregnancy?
What about natural treatments such as herbs and vitamins or behavioral treatments? Are these safe to use in pregnancy?
How long do patients need to be off of preventive medications before becoming pregnant?
Discussion
Diagnosis
Tip
A middle-aged woman with chronic migraine and paresthesias
Case
What was the most likely cause of this patient’s paresthesias?
Can topiramate-associated paresthesias be prevented or treated?
Discussion
Diagnosis
Tip
Will preventive treatment work in a patient who is overusing abortive treatments?
Case
Does this patient have medication overuse headache?
Is it always necessary to remove a medication that is suspected of producing medication overuse headache before instituting preventive treatment of migraine?
Discussion
Diagnosis
Tip
A woman on migraine treatment who has a fall
Case
Was this patient’s fall caused by her migraine treatment?
Could this have been prevented?
Discussion
Diagnosis
Tip
An older woman with blurry vision on amitriptyline
Case
What happened?
Discussion
Diagnosis
Tip
A woman with migraine worried about the long-term safety of topiramate
Case
What is known about the long-term risks of chronic topiramate treatment?
Discussion
Diagnosis
Tip
A woman worried about whether her contraceptive will work when she is on topiramate
Case
What is the interaction between topiramate and combination hormonal contraceptives?
Diagnosis
Tip
An older man treated for tension-type headache who has a seizure
Case
What happened?
Discussion
Diagnosis
Tip
A fatigued patient on two blood pressure medicines
Case
What was the likely cause of her fatigue?
Discussion
Diagnosis
Tip
How about Botox for episodic migraine?
Case
Is onabotulinumtoxinA the best therapeutic recommendation for this patient’s pattern of headache?
What therapy should be offered to the patient?
Discussion
Diagnosis
Tip
A young woman with headache after head trauma
Case
What factors predisposed this patient to the development of post-traumatic headache?
What treatment options are available for this patient?
Discussion
Diagnosis
Tip
9 Pitfalls in nonpharmacologic treatment of headache
A young woman with dietary triggers for headache
Case
What is the relationship between dietary factors and migraine?
What is the quality of evidence about dietary triggers for migraine and what is the best advice for this patient?
Discussion
Diagnosis
Tip
A young woman with frequent headaches attempting pregnancy
Case
Is this patient’s description of headache triggers likely to be accurate?
Is there a role for trigger avoidance in this case?
Discussion
Diagnosis
Tip
A woman with frequent headaches and multiple allergies
Case
What nonpharmacologic options are available to this patient?
How successful are these interventions likely to be?
Discussion
Diagnosis
Tip
A woman interested in natural treatments for migraine
Case
What vitamins or supplements might be recommended?
Would herbal treatments be helpful?
Discussion
Diagnosis
Tip
A middle-aged man with pain in the neck
Case
Was a diagnosis of migraine warranted?
What treatment should be suggested for this patient?
Discussion
Diagnosis
Tip
A man with frequent headaches interested in chiropractic treatment
Case
Is spinal manipulation likely to help his headaches?
What should he be told about risks associated with spinal manipulation?
Discussion
Diagnosis
Tip
A pregnant woman with cluster headaches
Case
What is the diagnosis, and what nondrug treatments might be considered?
How are greater occipital nerve blocks performed, and how often can they be repeated?
Discussion
Diagnosis
Tip
A woman with migraine aura who requests testing for a patent foramen ovale
Case
What is the relationship between migraine with aura and PFO?
Should patients who have migraine with aura be evaluated for a PFO and possible shunt closure?
Discussion
Diagnosis
Tip
A young woman asking about migraine surgery
Case
What is the “migraine surgery” this patient is referring to?
How strong is the evidence of benefit from migraine surgery?
Discussion
Diagnosis
Tip
10 Challenges and special situations in headache management
Lifelong migraine refractory to multiple treatments
Case
How is this patient’s recall of headaches likely to compare with diary information?
Would headache calendars or diaries be helpful in headache diagnosis or treatment here? Would paper or electronic diaries be better?
Discussion
Diagnosis
Tip
A patient with unrealistic expectations
Case
What elements of the visit predicted a suboptimal outcome?
What could have been done to end this visit on a more positive note?
Discussion
Diagnosis
Tip
Chronification of migraine in a patient lost to follow-up
Case
What may have contributed to the increased frequency of this patient’s headaches?
What could have been done to prevent the transition to chronic migraine?
Discussion
Diagnosis
Tip
A patient requesting early refills
Case
Are this patient’s treatment goals realistic?
What are reasonable limits on medication use? How much medication is “too much” or “too frequent” when it comes to treating individual attacks of headache?
What is the best way to handle this patient’s request for medication?
Discussion
Diagnosis
Tip
A woman requesting treatment with opioids
Case
Should the physician continue her oxycodone prescription? What important information is missing in this case?
How can a patient’s risk for opioid misuse, addiction, or dependence be assessed?
Discussion
Diagnosis
Tip
A patient with recurrent medication overuse headache
Case
What additional diagnosis is suggested by this patient’s presentation?
What additional clinical features suggest that management of this patient will be challenging?
Discussion
Diagnosis
Tip
Medication agreements
Case
Could a different approach to initial management have led to a better outcome?
What is the best management at this point?
Discussion
Diagnosis
Tip
11 Medicolegal pitfalls in headache management
Medical leave and disability determination: when to make the call?
Case
Did the physician respond appropriately to this patient’s request for disability?
Discussion
Diagnosis
Tip
Is the patient really disabled?
Case
How should the physician respond to this request for a determination of disability?
Discussion
Diagnosis
Tip
Shouldn’t someone help?
Case
Should this patient be advised to seek disability?
Discussion
Diagnosis
Tip
A patient who asks to record his office visit
Case
Is the request to record the visit reasonable and should it be allowed?
What are the potential pitfalls or harms associated with recording of medical visits?
Discussion
Diagnosis
Tip
Overreliance on steroids in cluster headache
Case
What is the role of corticosteroids in the treatment of cluster headache?
How can steroid dependence and complications be avoided?
Discussion
Diagnosis
Tip
A request for medical marijuana to treat migraine
Case
What are the legal implications of supporting a patient’s request for medical marijuana?
What advice should be given to this patient about the harms and benefits of marijuana in headache treatment?
Discussion
Diagnosis
Tip
Risks associated with prescribing off-label medication
Case
Did the provider do anything wrong?
How can this situation best be handled?
Discussion
Diagnosis
Tip
Index