neurologic disorders
Migraine
Diagnosis of Migraine
Clinical evaluation Diagnosis of migraine is based on characteristic symptoms and a normal physical examination, which includes a thorough Introduction to the Neurologic Examination . Red flag findings that suggest an alternate diagnosis (even in patients known to have migraine) include the following: Pain that reaches peak intensity within a few seconds or less (thunderclap headache) Onset after age 50 Headaches that increase in intensity or frequency for weeks or longer History of cancer (brain metastases) or an immunosuppressive disorder (eg, HIV infection, AIDS) Fever, meningismus, altered mental status, or a combination Persistent focal neurologic deficits Papilledema None A clear change in an established headache pattern Patients with characteristic symptoms and no red flag findings do not require testing. Patients with red flag findings often require Testing , including MRI and sometimes lumbar puncture. Common diagnostic errors include the following: Not realizing that migraine often causes bilateral pain and is not always described as throbbing Misdiagnosing migraine as sinus headache or eye strain because autonomic and visual symptoms of migraine are absent Assuming that any headache in patients known to have migraine represents another migraine attack (a thunderclap headache or a change in the previous headache pattern may indicate a new, potentially serious disorder) Mistaking migraine with aura for a transient ischemic attack, especially when the aura occurs without headache, in older people Diagnosing a thunderclap headache as migraine because a triptan relieves it (a triptan can also relieve a headache due to subarachnoid hemorrhage) Several unusual disorders can mimic migraine with aura: Dissection of the carotid or vertebral artery Cerebral vasculitis Moyamoya disease CADASIL (cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy) Mitochondrial encephalomyopathy, lactic acidosis, and strokelike episodes (MELAS) (mitochondrial encephalopathy, lactic acidosis, and strokelike episodes) syndrome 