Causes of 4-Day Migraine in a 30-Year-Old Female with Normal CT
This is most likely a primary migraine attack (migraine without aura) that has progressed to status migrainosus, defined as a migraine attack lasting more than 72 hours, rather than a secondary cause requiring further imaging. 1
Why the Normal CT is Reassuring
The probability of finding a clinically significant intracranial abnormality in a migraine patient with a normal neurological examination is only 0.2%, which is no higher than the rate of incidental findings in completely asymptomatic individuals (0.4%). 2, 1 Neuroimaging is not usually warranted for patients with migraine and normal neurological examination. 2, 1
Primary Causes to Consider
Status Migrainosus
- A migraine attack persisting beyond 72 hours (4 days in this case) represents status migrainosus, a recognized complication of episodic migraine. 3
- This occurs when the typical migraine mechanisms (cortical spreading depression, trigeminovascular activation, and meningeal inflammation) fail to resolve spontaneously. 4, 5
Hormonal Triggers
- In women of reproductive age, hormonal fluctuations are among the most important migraine triggers. 6
- Menstruation-related estrogen withdrawal commonly precipitates prolonged migraine attacks. 7, 6
- Elevated prolactin levels have been associated with migraine attacks in young women (mean 152.7 mIU/L in migraineurs vs 76.1 mIU/L in controls, p<0.001). 7
Stress and Psychological Factors
- Anxiety and depression-related stress are significantly higher in migraine patients, with an odds ratio of 12 for stress in migraineurs compared to non-migraineurs. 7
- Women are particularly vulnerable to stress-triggered migraine, especially in the premenstrual period. 7
When Further Imaging Would Be Indicated
You should reconsider the diagnosis and obtain MRI if any of these red flags are present: 1
- Abnormal findings on neurological examination 2, 1
- Headache that awakens from sleep 1
- Progressive worsening over weeks (this patient has 4 days, which doesn't meet this threshold) 1
- Headache worsened by Valsalva maneuver 2, 1
- New-onset headache in a patient over 50 years (not applicable here) 1
- Rapid increase in headache frequency 1
Important caveat: While CT is adequate for excluding hemorrhage and large masses, MRI is more sensitive for detecting ischemia, venous thrombosis, and smaller lesions. 8 However, given the normal neurological examination and typical migraine features, the yield would remain extremely low (0.2%). 1
Management Implications
The 4-day duration indicates this patient needs acute rescue therapy for status migrainosus, not further diagnostic workup. 2
- First-line acute treatment includes NSAIDs (aspirin, ibuprofen, naproxen sodium) or the acetaminophen-aspirin-caffeine combination. 2
- For moderate-to-severe attacks not responding to NSAIDs, triptans or dihydroergotamine (DHE) should be used. 2
- Intravenous metoclopramide may be appropriate, particularly given the likely presence of nausea after 4 days. 2
- Limit acute treatment to no more than twice weekly to prevent medication-overuse headache. 2
This patient should also be evaluated for preventive therapy given the severity and duration of this attack, as chronic migraine is defined as headaches on ≥15 days per month for ≥3 months. 3 Preventing progression from episodic to chronic migraine is a key treatment goal. 3