What causes a mild to moderate generalized headache with gradual onset and numbness in the fingertips of one hand in a 33-year-old female with no significant medical history and mildly elevated blood pressure (hypertension)?

Migraine with Aura is the Most Likely Diagnosis

This presentation of mild-to-moderate generalized headache with unilateral fingertip numbness in a young woman strongly suggests migraine with aura, specifically sensory aura. 1, 2

Clinical Reasoning

The combination of headache with unilateral sensory symptoms (fingertip numbness) fits the diagnostic criteria for migraine with aura. 2 Sensory aura occurs in approximately 31% of individuals with migraine and typically manifests as predominantly unilateral paresthesia (pins and needles and/or numbness) that spreads gradually in the face or arm. 1

Key Diagnostic Features Supporting Migraine with Aura:

• Age and sex: Onset at or around puberty is typical, and this 33-year-old female fits the demographic profile 1
• Sensory symptoms: Unilateral fingertip numbness is characteristic of sensory aura, which should develop gradually over ≥5 minutes and last 5-60 minutes 1, 2
• Headache characteristics: Mild-to-moderate generalized headache with gradual onset is consistent with migraine, though bilateral pain occurs in ~40% of migraine cases 1

Blood Pressure Consideration

The BP of 139/95 mmHg represents stage 1 hypertension. 1 However, mild chronic hypertension does NOT typically cause headache—headache is only attributed to hypertension when BP is substantially elevated (commonly >200/120 mmHg) and associated with acute end-organ damage. 1, 3 This patient's BP is insufficient to explain the headache. 4, 3

Importantly, migraine patients have an increased risk of developing hypertension, and hypertension is a risk factor for chronic transformation of episodic migraine. 4

Critical Red Flags to Exclude

Immediate neuroimaging (MRI brain preferred) is indicated if any of the following are present: 5, 2, 6

• Abnormal neurologic examination findings that persist beyond typical aura duration (>60 minutes)
• "Thunderclap" headache (sudden, severe onset)
• Progressive worsening of symptoms
• Fever or systemic symptoms
• Focal neurological deficits beyond typical aura
• Altered consciousness, memory, or personality changes
• Neck stiffness or limited neck flexion

Specific concerns to rule out in this presentation: 5

• Stroke/TIA: Atypical aura with prolonged focal neurological symptoms requires urgent evaluation
• Spontaneous intracranial hypotension: Would present with orthostatic headache (worsens upright, improves lying flat) 5, 7
• Hypertensive emergency: Would require BP >200/120 mmHg with acute end-organ damage 1

Immediate Management Steps

1. Perform Focused Neurological Examination 5, 2

• Document duration and progression of sensory symptoms
• Check for other focal deficits (motor weakness, speech disturbance, visual changes)
• Assess for papilledema, neck stiffness, altered mental status
• Verify symptoms are resolving or have resolved within 60 minutes

2. Acute Treatment (if diagnosis confirmed and no red flags) 2

• First-line: NSAIDs such as ibuprofen 400-800 mg or naproxen sodium 500-825 mg 2
• Second-line: Triptans if NSAIDs fail after three consecutive attacks 2
• Antiemetics if nausea present 1

3. Cardiovascular Risk Assessment 2

• Check for oral contraceptive use (contraindicated in migraine with aura due to stroke risk)
• Assess smoking status
• Document family history of stroke or migraine
• Address the stage 1 hypertension with lifestyle modifications and consider antihypertensive therapy

Follow-Up and Preventive Strategy

Re-evaluation in 2-3 months is recommended to assess: 2

• Attack frequency and response to acute treatment
• Need for preventive therapy (indicated if ≥2 attacks per month causing disability)
• Medication overuse patterns
• Use of headache diary to track triggers and frequency

Preventive treatment options if needed: 2

• First-line: Propranolol 80-160 mg daily, metoprolol, or topiramate
• These agents also provide benefit for hypertension management

When to Refer to Neurology 5, 2

Urgent referral (within 48 hours): 5

• Any red flag symptoms present
• Patient unable to self-care

Routine referral (2-4 weeks): 5, 2

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

Common Pitfalls to Avoid

• Do not attribute headache to mild hypertension (BP 139/95)—this level does not cause headache 3
• Do not miss atypical aura features that could indicate stroke/TIA—if sensory symptoms last >60 minutes or are associated with motor weakness, obtain urgent neuroimaging 5, 2
• Do not prescribe triptans if cardiovascular risk factors are present without appropriate screening 2
• Do not continue oral contraceptives if migraine with aura is confirmed due to increased stroke risk 2