Diagnosis: Migraine Without Aura
This 29-year-old female presents with classic migraine without aura, and imaging is NOT warranted given her age, typical migraine features, and absence of red flags. 1, 2
Clinical Diagnosis
The patient's presentation fulfills diagnostic criteria for migraine without aura:
- Throbbing, bitemporal headache with moderate to severe intensity 1, 2
- Nausea and vomiting - present in over 90% and 70% of migraineurs respectively, and crucial for diagnosis 3
- Loss of appetite - consistent with gastrointestinal disturbances that are nearly universal in migraine 4, 3
The diagnosis requires at least 5 qualifying attacks with these features, but even a single attack meeting criteria strongly suggests migraine, particularly in a young adult. 1, 5
Imaging Is NOT Indicated
Neuroimaging should NOT be performed in this patient because she lacks red flags and has a normal neurologic examination. 1, 2
Red Flags That Are ABSENT in This Case:
- No sudden "thunderclap" onset 2, 6
- Not awakening from sleep 1, 2
- Not worsened by Valsalva maneuver 1, 2
- Age under 50 (not new-onset in older adult) 2, 6
- No progressive worsening pattern 2, 6
- No abnormal neurologic examination findings 1, 2
- No focal neurological deficits 6
The conservative approach mentioned in older guidelines applies only when neurologic symptoms are present or examination is abnormal - neither applies here. 1
Evidence Against Routine Imaging:
- In patients with normal neurologic examination and typical migraine features, neuroimaging yield is extremely low (0.2-0.5%) 6
- The medical history is the mainstay of migraine diagnosis; imaging serves only to exclude secondary causes when clinically suspected 1
- Physical examination in migraine is typically normal and confirmatory rather than diagnostic 1
Critical Diagnostic Pitfall to Avoid
Do not order imaging simply because the patient has severe symptoms or prominent nausea/vomiting. These are characteristic features of migraine itself, not warning signs of secondary pathology. 1, 3 Nausea occurs in more than 90% of migraineurs and vomiting in nearly 70%, making them core diagnostic features rather than red flags. 3
Immediate Management Approach
For this moderate to severe migraine with prominent nausea/vomiting, use migraine-specific therapy (triptans) combined with antiemetics, not simple analgesics alone. 1, 7
- First-line treatment: Triptan (rizatriptan 10 mg, eletriptan 80 mg, or almotriptan 12.5 mg provide highest likelihood of consistent success) 7
- Antiemetic: Required given prominent nausea/vomiting, as 30.5% of patients with nausea and 42.2% with vomiting cannot tolerate oral medications 3
- Avoid opioids: Risk of dependency, rebound headaches, and loss of efficacy 1
Monitor frequency: if she develops ≥2 headaches per week, initiate preventive therapy to avoid progression to chronic migraine. 1, 2