What could cause a mild to moderate generalized headache with numbness in fingertips on one side in a 33-year-old woman with no significant medical history?

Migraine with Aura is the Most Likely Diagnosis

This presentation of unilateral fingertip numbness with headache in a young woman strongly suggests migraine with aura, specifically sensory aura preceding or accompanying the headache. 1, 2

Clinical Reasoning

The combination of headache with unilateral sensory symptoms (fingertip numbness) in a 33-year-old woman fits the diagnostic criteria for migraine with aura. 2 Sensory aura symptoms typically develop gradually over ≥5 minutes, last 5-60 minutes, and are followed by headache within 60 minutes. 2 The unilateral distribution is characteristic, as migraine is often unilateral and sensory aura commonly affects one side of the body. 3

Critical Red Flags to Exclude First

Before assuming this is benign migraine, you must actively rule out dangerous secondary causes:

• Stroke or TIA: New-onset headache after age 50 is a red flag, but at age 33, stroke risk is lower unless cardiovascular risk factors exist. 4, 2 However, any focal neurologic deficit (numbness) with headache warrants careful evaluation. 1, 5

• Cortical vein thrombosis (CVT): This can present with headache and unilateral sensory symptoms, particularly in young women, especially postpartum or on oral contraceptives. 3 CVT should be suspected if symptoms are progressive, persistent, or associated with seizures. 3

• Cervical artery dissection: Can cause headache with unilateral sensory symptoms, though neck pain is usually prominent. 6

Immediate neuroimaging (MRI brain preferred) is indicated if: 1, 4, 2

• Abnormal neurologic examination findings persist beyond typical aura duration
• Headache is "thunderclap" (sudden, severe onset)
• Progressive worsening of symptoms
• Fever or systemic symptoms present
• First-ever episode of this type in this patient

Diagnostic Approach

If neurologic examination is normal and symptoms resolve within 60 minutes, migraine with aura is most likely and neuroimaging is not required. 2, 5 However, given this is apparently new-onset, consider:

1. Detailed history: Confirm gradual onset of numbness over ≥5 minutes, duration 5-60 minutes, followed by headache. 2 Ask about visual symptoms (flickering lights, zigzag lines), speech difficulties, or other aura features. 2

2. Cardiovascular risk assessment: Check blood pressure, ask about oral contraceptive use, smoking, family history of stroke or migraine. 3

3. If any uncertainty exists or examination shows persistent deficits, obtain MRI brain with MR venography to exclude CVT or stroke. 3, 4

Acute Treatment

For this mild-to-moderate headache, NSAIDs are first-line treatment: 3, 7

• Ibuprofen 400-800 mg or naproxen sodium 500-825 mg at headache onset 1, 7
• Add antiemetic (metoclopramide or domperidone) if nausea present 3

Triptans are second-line if NSAIDs fail after three consecutive attacks. 3 However, triptans should be avoided during aura phase and used only once headache begins. 7

Critical warning: Limit acute medication use to ≤2 days per week to prevent medication-overuse headache. 3, 1, 2

When to Consider Preventive Therapy

Preventive treatment should be initiated if attacks occur ≥2 times per month causing disability despite optimized acute treatment: 3, 1

• First-line: Propranolol 80-160 mg daily, metoprolol, or topiramate 3, 1
• Second-line: Amitriptyline or candesartan 3

Common Pitfalls to Avoid

• Do not dismiss unilateral sensory symptoms as "just anxiety" without confirming they fit the temporal pattern of migraine aura (gradual onset, 5-60 minute duration). 2

• Do not assume migraine if symptoms persist beyond typical aura duration (>60 minutes) or if weakness (rather than just numbness) is present—these require urgent imaging. 1, 5

• Do not start daily analgesics without establishing diagnosis, as this leads to medication-overuse headache. 4, 2

• In women of childbearing age, always ask about oral contraceptive use and pregnancy status, as these increase CVT risk and affect treatment choices. 3

Follow-Up Strategy

Re-evaluate in 2-3 months to assess: 1

• Attack frequency and response to acute treatment
• Need for preventive therapy
• Medication overuse patterns
• Consider headache diary to track triggers and frequency 1, 2

Refer to neurology if: 4

• Atypical features despite negative workup
• Attacks become more frequent or severe
• Poor response to first-line treatments
• Diagnostic uncertainty remains