Migraine Mimics
This 48-year-old woman was seen for a third opinion with a 20-year history of only menstrual headaches always preceded by a visual aura followed by a generalized throbbing with an intensity of 5–6/10 associated with light and noise sensitivity but no nausea. The headache would last 2–3 days with ibuprofen.
For 3.5 months, she had a daily constant headache, daily since onset, described as a left-sided pressure or throbbing with an intensity ranging from 1 to 10/10 with an average of 6/10 associated with light and noise sensitivity but no nausea, aura, or cranial autonomic symptoms. She had no triggers.
She had seen 2 headache specialists previously. She had been tried on sumatriptan p.o. and subcutaneously, diclofenac powder, ketorolac oral and intramuscular, dihydroergotamine nasal spray, and had an occipital nerve block without benefit. Gabapentin and pregabalin did not help. She was placed on indomethacin 75 mg sustained release once a day for 8 days without benefit. Prednisone 60 mg daily for 10 days did not help. An intravenous dihydroergotamine regimen for 5 days did not help.
A magnetic resonance imaging (MRI) and magnetic resonance angiogram (MRA) of the brain and cervical spine and magnetic resonance venogram (MRV) of the brain were negative. Blood tests were normal. There was a past medical history of asthma. Neurological examination was normal.
The author placed her on an increasing dose of indomethacin to 75 mg t.i.d. with omeprazole and she became pain free. She has been followed for almost 3 years. The pain resolved for 9 months without medication and then recurred and has been controlled with indomethacin 75 mg daily.
This is a 54-year-old female with a 3-year history of headaches which initially occurred perhaps 2 days per week and then daily and constant for 2 years. She described a left-sided stabbing, pressure, or tightness located on left top of the head, left posterior neck, and behind the left eye with an intensity of 6–10/10 associated with nausea, vomiting (5% of the time), light and noise sensitivity, and intermittent blurry vision. She reported left-sided tearing of the eye, redness, and nasal congestion when the pain was intense.
She had seen 2 neurologists. A MRI of the brain was normal. A erythrocyte sedimentation rate (ESR) was 38 mm per hour (but her body mass index was elevated at 39). She underwent a negative superficial temporal artery biopsy.
Sumatriptan orally and butalbital combination did not help. Intravenous ketorolac and valproic acid daily for 3 days did not help. She was on topiramate 100 mg daily for 2 years and indomethacin 75 mg daily for 5 months without improvement.
There was a past medical history of asthma and hypertension. Neurological examination was normal.
The author titrated up the dose of indomethacin to 75 mg 3 times daily with complete resolution of the headache.
What is the cause of these headaches? What are the clinical features and treatment? What are some other primary and secondary migraine mimics?
Case Histories
Case 1
This 48-year-old woman was seen for a third opinion with a 20-year history of only menstrual headaches always preceded by a visual aura followed by a generalized throbbing with an intensity of 5–6/10 associated with light and noise sensitivity but no nausea. The headache would last 2–3 days with ibuprofen.
For 3.5 months, she had a daily constant headache, daily since onset, described as a left-sided pressure or throbbing with an intensity ranging from 1 to 10/10 with an average of 6/10 associated with light and noise sensitivity but no nausea, aura, or cranial autonomic symptoms. She had no triggers.
She had seen 2 headache specialists previously. She had been tried on sumatriptan p.o. and subcutaneously, diclofenac powder, ketorolac oral and intramuscular, dihydroergotamine nasal spray, and had an occipital nerve block without benefit. Gabapentin and pregabalin did not help. She was placed on indomethacin 75 mg sustained release once a day for 8 days without benefit. Prednisone 60 mg daily for 10 days did not help. An intravenous dihydroergotamine regimen for 5 days did not help.
A magnetic resonance imaging (MRI) and magnetic resonance angiogram (MRA) of the brain and cervical spine and magnetic resonance venogram (MRV) of the brain were negative. Blood tests were normal. There was a past medical history of asthma. Neurological examination was normal.
The author placed her on an increasing dose of indomethacin to 75 mg t.i.d. with omeprazole and she became pain free. She has been followed for almost 3 years. The pain resolved for 9 months without medication and then recurred and has been controlled with indomethacin 75 mg daily.
Case 2
This is a 54-year-old female with a 3-year history of headaches which initially occurred perhaps 2 days per week and then daily and constant for 2 years. She described a left-sided stabbing, pressure, or tightness located on left top of the head, left posterior neck, and behind the left eye with an intensity of 6–10/10 associated with nausea, vomiting (5% of the time), light and noise sensitivity, and intermittent blurry vision. She reported left-sided tearing of the eye, redness, and nasal congestion when the pain was intense.
She had seen 2 neurologists. A MRI of the brain was normal. A erythrocyte sedimentation rate (ESR) was 38 mm per hour (but her body mass index was elevated at 39). She underwent a negative superficial temporal artery biopsy.
Sumatriptan orally and butalbital combination did not help. Intravenous ketorolac and valproic acid daily for 3 days did not help. She was on topiramate 100 mg daily for 2 years and indomethacin 75 mg daily for 5 months without improvement.
There was a past medical history of asthma and hypertension. Neurological examination was normal.
The author titrated up the dose of indomethacin to 75 mg 3 times daily with complete resolution of the headache.
Questions
What is the cause of these headaches? What are the clinical features and treatment? What are some other primary and secondary migraine mimics?
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