What is the most appropriate diagnosis for a patient with recurrent unilateral pulsating headaches, photophobia, phonophobia, nausea/vomiting, and no aura?

Migraine Without Aura

The appropriate diagnosis is migraine without aura, which requires at least five attacks fulfilling specific ICHD-3 criteria: headaches lasting 4-72 hours with at least two pain characteristics (unilateral location, pulsating quality, moderate-to-severe intensity, or aggravation by physical activity) plus at least one associated symptom (nausea/vomiting OR both photophobia and phonophobia). 111

Diagnostic Criteria Application

The patient's presentation directly maps to the ICHD-3 diagnostic criteria for migraine without aura 111:

Required Elements (All Must Be Present):

1. At least 5 attacks - The patient has recurrent episodes

2. Duration 4-72 hours - Confirmed in this case

3. At least 2 of 4 pain characteristics:

   • ✓ Unilateral location (present)
   • ✓ Pulsating quality (present)
   • ✓ Moderate or severe intensity (implied by presentation)
   • Aggravation by routine physical activity (not specified but not required if other 2 present)

4. At least 1 of the following:

   • ✓ Nausea and/or vomiting (present)
   • ✓ Photophobia AND phonophobia (both present)

5. Not better explained by another diagnosis - Must exclude secondary causes

Clinical Reasoning

The diagnosis is straightforward when the patient presents with the classic tetrad: unilateral pulsating headache with photophobia, phonophobia, and nausea/vomiting 12. Research demonstrates these features have high positive likelihood ratios for migraine: nausea (19.2), photophobia (5.8), and phonophobia (5.2) when compared to tension-type headache 2.

Important Clinical Pitfall

Be aware that bilateral pain occurs in approximately 40% of migraine patients 1, so the absence of strict unilaterality does not exclude migraine. The ICHD-3 criteria only require 2 of 4 pain characteristics, not all 4.

Questioning Technique Matters

When patients initially deny photophobia or phonophobia, ask more specific questions 3:

• Instead of "Does light bother you?" ask "Would you prefer bright sunlight or a dark room during your headache?"
• Instead of "Does noise bother you?" ask "Would you prefer loud music or a quiet room during your headache?"

Research shows 24% of migraine patients initially deny light/sound sensitivity but 93% acknowledge it with detailed questioning 3. Failure to ask these follow-up questions can lead to misdiagnosis as "probable migraine."

Differential Considerations

The absence of aura is critical - no visual disturbances (fortification spectra), sensory symptoms (paresthesias), or speech disturbances that gradually spread over ≥5 minutes 11. If aura symptoms were present, both diagnoses (migraine with aura AND migraine without aura) should be made, as they commonly coexist 11.

Exclude chronic migraine (requires ≥15 headache days/month for >3 months) 11 and medication-overuse headache if the patient uses acute medications ≥10-15 days/month for >3 months 11.

Diagnostic Workup

The medical history is the cornerstone of diagnosis 11. Physical examination serves primarily to exclude secondary causes. Neuroimaging is only indicated when secondary headache disorder is suspected 1, not for routine migraine diagnosis.

Document: age at onset, attack duration, frequency, pain characteristics (location, quality, severity), aggravating factors, associated symptoms, and medication use history 11. A positive family history strengthens the diagnosis, as migraine has strong genetic components 11.