Migraine

ABSTRACT: A thorough history and physical examination can establish the diagnosis of tension headache; further evaluation is generally unnecessary. In contrast, the workup of cervicogenic headache includes standard radiographs, 3-dimensional CT, MRI, and possibly electromyography; nerve blocks may also be used to confirm the diagnosis. Episodic tension headache can be treated effectively by trigger avoidance, behavioral modalities, and structured use of analgesics. Reserve opioids for patients with intractable headaches. Chronic tension headache is treated primarily by prophylactic measures, such as antidepressants and anticonvulsants, and behavioral and physical therapy. Treatment options for cervicogenic headache include analgesics; invasive procedures, such as trigger point injections, greater or lesser occipital nerve blocks, facet joint blocks, segmental nerve root blocks, and diskography; spinal manipulation; and behavioral approaches.

Anisocoria and partial eyelid ptosis were detected during the routine eye examination of a 66-year-old woman. These findings had not been present during an examination 2 years earlier. Because the patient had no symptoms, she could not recall when these signs began. Her general health was unremarkable; she had smoked 1 pack of cigarettes per day for 40 years

A bright, active 10-year-old boy has been experiencing recurrent bouts ofabdominal pain with nausea and occasional vomiting for 3 years. Although hehas had 1 or 2 attacks at school, the pain usually occurs at home-frequentlyon weekends. His mother has been unable to correlate these episodes with particularfoods or activities. She notes that her son has experienced motion sicknessduring long auto trips and during a family holiday in the mountains ofColorado.

A 37-year-old woman presents to the emergency departmentwith a diffuse, sharp, pounding headache,which started 2 hours earlier. She rates her discomfort as4 on a scale of 1 to 10. Neck muscle soreness is also present,but the pain does not radiate.

Three strategies have commonly been used for episodic migraine. In step care across attacks, the least expensive medications are tried for several episodes. If these fail, treatment is "stepped up" to specific agents.

Migraine is an episodic, often debilitatingcondition that affects women moreoften than men. Twenty-eight millionAmericans suffer from migraineheadaches-and nearly 75% of theseare women.1 Unlike other chronic painconditions, migraine has its peakprevalence during the years of greatestproductivity, when most women arejuggling family responsibilities andcareers.2 Many women are particularlysusceptible to migraine attacks justbefore and during menses.