Headache Disorders: Migraine, Cluster & Tension
A Step 2 CK-focused headache lesson that walks pathophysiology → pattern recognition → diagnosis → acute and preventive management for migraine, cluster, and tension-type headache, with red-flag vignettes and next-best-step decisions for dangerous secondary causes.
Framing the Headache Vignette
Headache is one of the most common Step 2 CK stems, and the exam's core task is separating benign primary headaches (migraine, tension-type, cluster) from dangerous secondary causes (subarachnoid hemorrhage, giant cell arteritis, meningitis, mass, idiopathic intracranial hypertension). Primary headaches are diagnosed clinically—neuroimaging is not indicated when the history is classic and the neurologic exam is normal.
Migraine pathophysiology centers on the trigeminovascular system and release of calcitonin gene-related peptide (CGRP), driving neurogenic inflammation and sensitization; aura reflects cortical spreading depression, a slow wave of neuronal depolarization followed by suppression. Cluster headache is a trigeminal autonomic cephalalgia driven by posterior (ventral) hypothalamic activation; the trigeminal-autonomic reflex produces ipsilateral cranial parasympathetic overactivity (lacrimation, rhinorrhea) plus sympathetic hypofunction (partial Horner—ptosis/miosis). Tension-type headache arises from pericranial myofascial nociception and central sensitization.
The high-yield skill: recognize the classic pattern, choose the correct acute and preventive therapy—or, when a red flag appears, choose the correct next diagnostic step.
- Migraine: unilateral, pulsatile/throbbing, moderate–severe, 4–72 h, worsened by activity; photophobia + phonophobia, nausea/vomiting; patient prefers to lie still in a dark room
- Aura: develops gradually over 5–20 min, lasts <60 min, fully reversible; classically scintillating scotoma / fortification spectra—the gradual build-up of positive symptoms distinguishes it from TIA (sudden, negative/deficit symptoms), and the slow march over minutes distinguishes it from seizure (spreads over seconds)
- Cluster: excruciating unilateral periorbital pain, 15–180 min, circadian/nocturnal, in bouts; ipsilateral lacrimation, rhinorrhea, conjunctival injection, ptosis/miosis; patient is restless/agitated and paces
- Tension: bilateral, band-like pressing/tightening, mild–moderate, not worsened by activity, no nausea; the most common primary headache
- Migraine with aura + combined estrogen contraceptive → ↑ ischemic stroke risk → use progestin-only or non-hormonal method
- Classic pattern + normal exam → no neuroimaging
Migraine vs. Cluster vs. Tension
| Feature | Migraine | Cluster | Tension-type |
|---|---|---|---|
| Location | Unilateral | Unilateral, periorbital | Bilateral, band-like |
| Quality | Throbbing/pulsatile | Boring, stabbing, excruciating | Pressing/tightening |
| Duration | 4–72 h | 15–180 min | 30 min–7 days |
| Sex | Female > male | Male > female | Female > male |
| Behavior | Lies still, dark room | Restless, paces | No specific behavior |
| Autonomic signs | Usually none | Prominent ipsilateral (tearing, rhinorrhea, ptosis/miosis) | None |
| Associations | Photo- + phonophobia, N/V, ± aura | Nocturnal, alcohol trigger | Pericranial tenderness |
| Acute Rx | Triptan/NSAID ± antiemetic | 100% O₂, SC sumatriptan | NSAID/acetaminophen |
| Prevention | Propranolol, topiramate, amitriptyline, CGRP mAb | Verapamil | Amitriptyline |
Stem: A 28-year-old woman has recurrent right-sided throbbing headaches lasting most of a day, each preceded by ~20 min of shimmering zig-zag lines drifting across her left visual field. She lies in a dark room with nausea. Neurologic exam is normal.
Diagnosis: Migraine with aura.
Next steps / management:
- No imaging—classic history, normal exam.
- Acute: oral triptan (5-HT₁B/₁D agonist) or NSAID; add an antiemetic (metoclopramide) for nausea. Treat early.
- Triptan contraindications to screen: ischemic CAD/PAD, uncontrolled hypertension, prior stroke, hemiplegic or brainstem-aura migraine, pregnancy → use NSAID, a gepant (ubrogepant/rimegepant), or lasmiditan (5-HT₁F, no vasoconstriction).
- Prevention if ≥4 headache-days/month or disabling: propranolol, topiramate, amitriptyline, valproate, or a CGRP monoclonal antibody (e.g., erenumab).
- She takes a combined OCP—migraine with aura raises stroke risk → switch to a progestin-only/non-hormonal method and counsel smoking cessation.
Stem: A 40-year-old man is awakened nightly by 45-minute attacks of agonizing left retro-orbital pain with left tearing, nasal congestion, and a drooping eyelid. He paces the room clutching his eye. Attacks have recurred daily for 3 weeks; alcohol provokes them.
Diagnosis: Cluster headache (a trigeminal autonomic cephalalgia); a partial Horner (ptosis/miosis) may be seen.
Next steps / management:
- First presentation → MRI brain (attention to pituitary/cavernous sinus and posterior fossa) to exclude a secondary mimic before labeling it primary.
- Acute (abort): 100% oxygen 12–15 L/min by non-rebreather for ~15 min and/or subcutaneous sumatriptan (fastest). Oral agents act too slowly.
- Transitional bridge: short prednisone taper or occipital nerve block while a preventive takes effect.
- Prevention (first-line): verapamil—get a baseline ECG (bradycardia/heart-block risk) before uptitrating. Alternatives: lithium, galcanezumab.
- Counsel alcohol avoidance during an active bout.
- "Worst headache of my life," thunderclap, peaks in seconds → subarachnoid hemorrhage → non-contrast head CT first; if negative but suspicion persists → lumbar puncture for xanthochromia/RBCs → CTA to find the aneurysm.
- Age >50, new headache, jaw claudication, scalp tenderness, ↑ESR/CRP, transient monocular vision loss → giant cell (temporal) arteritis → start high-dose corticosteroids IMMEDIATELY (do not wait for biopsy) → temporal artery biopsy confirms; untreated → irreversible arteritic AION blindness.
- Obese young woman, daily headache, pulsatile tinnitus, transient visual obscurations, papilledema, CN VI palsy → idiopathic intracranial hypertension → MRI + MRV (exclude venous sinus thrombosis) → LP: opening pressure >25 cm H₂O, normal CSF → acetazolamide + weight loss.
- Fever, neck stiffness, photophobia → meningitis → LP (CT head first only if focal deficit, papilledema, immunocompromised, or altered mental status).
- Positional, worse in morning / with Valsalva, projectile vomiting → raised ICP / mass → MRI.
POUND — likelihood of migraine (≥4 of 5 present → high probability):
- P — Pulsatile/throbbing quality
- O — duration One day (4–72 hours)
- U — Unilateral
- N — Nausea/vomiting
- D — Disabling intensity
SNOOP — secondary-headache red flags (prompt work-up/imaging):
- S — Systemic symptoms (fever, weight loss) or Systemic disease (cancer, HIV/immunosuppression)
- N — Neurologic signs/symptoms (focal deficit, papilledema, seizure, altered mental status)
- O — Onset sudden/thunderclap
- O — Older age of onset (>50)
- P — Pattern change, Positional, Precipitated by Valsalva, Papilledema, Pregnancy
- Acute migraine: treat early; triptans (5-HT₁B/₁D) are first-line for moderate–severe—avoid in CAD/PAD, uncontrolled HTN, prior stroke, hemiplegic/brainstem-aura migraine, pregnancy
- Non-vasoconstricting acute options: gepants (ubrogepant, rimegepant) and lasmiditan (5-HT₁F)—use when triptans are contraindicated
- Medication-overuse headache: frequent triptans/combination or simple analgesics (~≥10–15 days/month) → chronic daily headache → withdraw the offending drug
- Migraine prevention (≥4 days/month or disabling): propranolol, topiramate (weight loss; kidney stones, teratogenic), amitriptyline, valproate (avoid in pregnancy), CGRP mAbs; onabotulinumtoxinA for chronic migraine (≥15 days/month)
- Cluster: acute = O₂ + SC sumatriptan; prevention = verapamil
- Tension-type: acute = NSAID/acetaminophen; prevention = amitriptyline
- Migraine is an independent risk factor for ischemic stroke, amplified by aura, smoking, and estrogen
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