What type of headache does an older woman with recurrent left‑temporal throbbing pain, nausea, photophobia, phonophobia, and visual aura (flashes/blue spots) have?

Migraine with Aura

This patient has migraine with aura (classic migraine), characterized by the visual disturbances (flashes and blue spots) that precede or accompany the throbbing headache, along with nausea, photophobia, and phonophobia. 1

Diagnostic Reasoning

The clinical presentation meets the International Classification of Headache Disorders (ICHD-3) criteria for migraine with aura based on several key features:

Visual Aura Symptoms

• The visual phenomena of flashes and blue spots are classic manifestations of migraine aura, occurring in over 90% of patients who experience aura. 1, 2
• Visual aura typically includes dots or flashing lights, wavy or jagged lines, blind spots, and tunnel vision—this patient's "flashes and blue spots" fit this pattern. 3
• These symptoms develop gradually over at least 5 minutes and last 5-60 minutes, distinguishing them from sudden-onset vascular events like transient ischemic attacks. 4, 5

Headache Characteristics

• The unilateral (left temple), throbbing, dull pain with moderate to severe intensity meets at least two of the four required headache characteristics for migraine diagnosis. 1, 5
• The headache duration of 4-72 hours (implied by the episodic nature) satisfies the temporal criteria. 5

Associated Symptoms

• Nausea, photophobia (sensitivity to light), and phonophobia (sensitivity to sound) are the defining associated symptoms that must accompany migraine attacks. 1
• The presence of both photophobia AND phonophobia together, along with nausea, strongly supports the diagnosis. 5

Attack Frequency

• The progression from monthly to twice-weekly attacks indicates episodic migraine, though this increasing frequency warrants monitoring for potential evolution to chronic migraine (≥15 headache days per month). 4

Critical Diagnostic Considerations

Why This Is Migraine With Aura and Not Other Headache Types

Cluster headache is excluded because:

• Cluster attacks last only 15-180 minutes (0.25-3 hours), not the 4-72 hours typical of migraine. 6
• Cluster headache presents with severe periorbital pain and prominent autonomic symptoms (lacrimation, rhinorrhea), which are absent here. 6
• Patients with cluster headache are typically restless and agitated, not seeking quiet dark rooms like migraine patients. 6

Tension-type headache is excluded because:

• Tension headaches are bilateral, pressing/tightening (not throbbing), and mild-to-moderate in intensity without nausea or photophobia/phonophobia together. 1, 6

Approximately One-Third of Migraine Patients Experience Aura

• About 31% of those with aura experience sensory symptoms (numbness, tingling) in addition to or instead of visual symptoms. 1, 5
• The aura phase usually precedes but can sometimes accompany the headache phase. 1, 2

Important Clinical Pitfalls

Red Flags to Exclude Secondary Causes

• New-onset visual symptoms in an older woman require careful evaluation to ensure they fit the typical migraine pattern and are not indicative of other pathology. 4
• Sudden (not gradual) onset of symptoms, persistent neurological deficits that don't resolve, or loss of consciousness would mandate urgent neuroimaging to exclude stroke, TIA, or other vascular pathology. 4, 5
• If symptoms correspond to a specific cerebral vascular territory or occur simultaneously rather than in succession, emergency evaluation for TIA is necessary. 2

Age Considerations

• In older patients, secondary headache disorders, comorbidities, and adverse events from medications are all more likely, requiring heightened vigilance. 1
• The evidence base for migraine treatments is poor in older populations, necessitating careful medication selection. 1

Next Steps in Management

Documentation and Monitoring

• Implement a headache diary to track attack frequency, duration, aura characteristics, associated symptoms, and medication use to determine if the pattern is evolving toward chronic migraine. 4, 5
• Systematically apply ICHD-3 criteria as a checklist rather than relying on clinical impression alone. 4

Physical Examination

• Perform a thorough neurologic examination to exclude other causes, though the examination is typically normal in migraine and serves primarily to rule out secondary disorders. 1, 4
• Neuroimaging should only be used when a secondary headache disorder is suspected based on red flags or atypical presentation. 1, 4

Treatment Approach

• First-line acute treatment consists of NSAIDs (ibuprofen, diclofenac, or aspirin) started as soon as possible during the aura phase to prevent or diminish the subsequent headache. 1, 2
• Triptans are second-line and should be used when the headache begins if NSAIDs fail. 1, 2
• Consider prophylactic treatment given the increasing frequency (now twice weekly), using medications such as propranolol, amitriptyline, or topiramate. 1