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“Just Another Headache”

A 55-year-old woman with a 35-year history of migraine headaches had a follow-up visit with her neurologist. Her headaches had been preceded by scintillating scotomas, but she noted increasing visual scotomas, especially in the right field of vision. She was not very concerned, as she stated that it was “just another headache.” Neurologic examination including visual field testing by confrontation was normal. However, magnetic resonance imaging of the brain showed a large pituitary macroadenoma (Figure). She underwent successful transsphenoidal excision with no residual complications. 
 
 
 
Figure 
 
(a) Sagittal and (b) axial postcontrast T1-weighted magnetic resonance images of the brain showing a large elliptical avidly enhancing mass measuring 3.5 × 2.9 cm filling the sella turcica and the suprasellar cistern and compressing the optic ... 
 
 
 
A history of rapidly increasing headache frequency, lack of coordination, localized neurologic signs, or subjective numbness or tingling has been found to be associated with significantly increased odds of finding an abnormality on neuroimaging (1). Physicians should keep in mind that almost one quarter of patients with pituitary adenomas have a normal neuroophthalmological examination (2). This case stresses the importance of neuroimaging in patients with chronic headaches who present with increased headache frequency or a change in the character of their symptoms.