Event 1: Meet Joe

Migraine is a Common Condition

Bar chart of migraine prevalence in women, men and children
Migraine prevalence

History and Physical Exam

  • Graduate student
  • Increasing headache frequency for past 2-3 months
  • Headaches occur daily and disrupt coursework and studying
  • Some headaches are severe with nausea and light sensitivity
  • Some are mild headaches
  • Associated neck pain and muscle tension

Medical History Interview

Joe describes his history of headache.

Test Your Knowledge

What kind of headaches do you think Joe is having?


Criteria for Migraine Without Aura

International Criteria for Headache Disorders 3 (ICHD3)

(required) A

  • >5 attacks filling criteria B-D

(required) B

  • Last 4-72 hours

(at least 2) C

  • Unilateral location
  • Pulsating quality
  • Moderate or severe pain intensity
  • Aggravated by or causes avoidance of routine physical activity

(at least 1) D

  • Nausea and/or vomiting
  • Photophobia and phonophobia

4 Nonobligatory Phases

Migraines are associated with 4 nonobligatory phases.

Migraine phases
Migraine phases

Not all patients experience all four of these phases.

Test Your Knowledge

Joe’s headaches were infrequent and now occur daily. He is concerned that his headache is being caused by a brain tumor. So he thinks he needs a CT scan. True or false: Joe should get a CT scan.


SNOOP Criteria

The SNOOP criteria list worrisome headache red flags that may indicate need for MRI.

  • Systemic symptoms (fever, weight loss) and/or Secondary risk factors (HIV, cancer)
  • Neurologic symptoms or abnormal signs (confusion, ↓ alertness, impaired consciousness)
  • Onset: sudden, abrupt, or split-second
  • Older age: new onset and progressive headache
  • Positional headache, papilledema, or prior headache now worsening

Episodic Migraine

Episodic migraine headaches may transform into chronic migraine.

Illustration showing episodic migraine transitioning to chronic migraine
Episodic migraine transition to chronic migraine

Risk Factors for Chronic Migraine

Several factors increase risk for chronic migraine:

  • Female Gender
  • Obesity
  • Anxiety and depression
  • Head injury
  • Sleep apnea
  • Medication overuse

Thorough Medical History

A thorough medical history is the first step in diagnosing Joe’s chronic headaches.

  • Full time student (spends several hours daily sitting at computer studying)
  • Daily caffeine (1 cup of coffee in the AM), occasional alcohol (weekends), no tobacco or drugs
  • Reports significant stress from heavy class schedule
  • Since starting graduate school work, sleep and exercise habits have changed
    • Irregular sleep hours
    • Works late into the evening 
    • Limited physical activity

Physical Exam

Dr. Bernstein performs a full physical exam including neurological tests.

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