A 14-year-old boy presents with frequent severe headaches characterized by sharp, throbbing pain behind his left eye and left temple.
Alexander Feoktistov, MD, PhD
A 47-year-old woman complains of severe headaches that involve only the right orbital, temporal, and occipital areas. She describes the pain as sharp and stabbing, and she rates its severity as 9 or 10 on a 10-point visual analog scale.
The headaches vary in severity, but she usually has severe
headaches (8 on a 10-point visual analog scale
[VAS]) once or twice a week; she describes the latter as
severe throbbing or pounding pain on the top of the
head but also involving the occipital and frontal
areas and occasionally one or the other temple.
A 12-year-old boy complains of severe weekly headaches that last 2 to 3 hours. The pain involves both sides of
the head and the frontal and occipital areas. Occasionally during a headache, the patient complains of some abdominal
discomfort and pain. He becomes passive and irritable during the headache; he does not want to be around
people, play, or even watch TV. The patient’s parents note that a few hours before a headache, he becomes somewhat
restless and agitated. The headaches started about 1 year earlier, and the headache pattern (frequency, duration,
location of pain, and associated symptoms) has not changed since that time. The patient’s mother and maternal
grandmother suffer from migraine.
Primary care doctor: Because of the patient’s age and the
absence of a headache history, I first considered such secondary
causes as tumor and temporal arteritis. However,
MRI of the brain and erythrocyte sedimentation rate were
normal. I now suspect a sleep-related headache because
the attacks occur only at night and awaken the patient
from a sound sleep. How can I determine which type of
sleep-related headache is involved?
A 37-year-old woman complains of frequent, severe headaches. She describes the pain as a pressure-like feeling that is usually located at the top of her head and occasionally spreads to one of her temples; she rates its intensity as 9 on a 10-point visual analog scale. The pain becomes throbbing when she tries to engage in any kind of physical activity.
The patient is a 47-year-old white woman with frequent, intensely painful unilateral or bilateral headaches that occur behind her left eye or temporal area. These headaches cause throbbing pain that lasts about 40 to 50 minutes: the patient rates the pain severity as a 7 or 8 on a 10-point visual analog scale.
A 15-year-old boy complains of moderate to severe headaches that occur daily and usually last all day; the pain typically worsens toward the end of the day. How will you help this patient?
A neurologic deficit caused by a transient ischemic attack should last less than 24 hours. This woman presented with signs of paresis that had persisted for 36 hours, thus ruling out transient ischemic attack.
A 39-year-old man complains of severe daily headaches that he describes as throbbing and "burning," with a sensation
of pressure. He rates the severity of his pain as 8 to 10 on a 10-point visual analog scale (VAS) in which 10 is
the most severe. The mean duration of the headaches is 12 hours, and the mean frequency is 5 days per week. Between
the episodes of severe headache, he has constant "minor" headaches that are not as severe (mean severity, 3 to 5 on a
10-point VAS). Within the past 5 months, he has never been totally free of headache.