Update your Knowledge with MKSAP 19 Q&A: Answer and Critique


B: Migraine headache

Educational Objective

Diagnose migraine.


The most likely diagnosis is migraine (Option B). Migraine is the most common severe headache in both population-based and clinic-based studies. Annual prevalence for migraine approximates 13% of adults, and greater than 90% of headache visits to primary care and specialty settings involve migraine. According to criteria published in the International Classification of Headache Disorders, 3rd edition, migraine involves recurrent attacks (at least 5 lifetime) of head pain lasting, without treatment, from 4 to 72 hours. The pain of migraine involves at least two of four features (unilateral location, throbbing nature, moderate to severe intensity, worsening with routine physical activity) and is associated with at least one of two features: (1) nausea and/or vomiting and (2) photophobia and phonophobia. Neurologic examination is typically normal. Migraine may be subclassified qualitatively (with or without aura) and quantitatively (episodic or chronic). Migraine in patients reporting visual or neurologic symptoms meeting appropriate criteria will be subclassified as migraine with aura, but very few patients with migraine will ever experience aura. The number of total headache days per month differentiates episodic (<15 days) from chronic (15 or more days) migraine. Because of the extensive phenotypic variation, nearly half of migraine presentations are misdiagnosed. Neck pain (75%) and “sinus” symptoms, such as tearing or nasal drainage (50%), are both more common than features felt to be characteristic of migraine, such as vomiting or aura.

Cluster headache (Option A) may be severe or throbbing and may result in nausea and nasal congestion or drainage. However, cluster headache pain is strictly unilateral, and attacks by definition do not extend beyond 3 hours without treatment.

Primary stabbing (Option C) headache involves episodes of stabbing head pain lasting seconds and occurring in isolation or in series. There are no associated autonomic features. The attacks described by this patient are much longer in duration. The location of pain is fixed in one third of patients and extratrigeminal in most patients. Indomethacin can be helpful during cycles of more frequent attacks.

Nausea, severe intensity, throbbing quality, and resultant disability from headache pain are not features seen with tension-type headache (Option D).

Key Points

Migraine is the most common severe headache.

Established criteria for migraine include recurrent attacks of head pain lasting from 4 to 72 hours without treatment, involving at least two of four features (unilateral location, throbbing nature, moderate-severe intensity, worsening with routine physical activity), and possessing at least one of the following two associations: (1) nausea and/or vomiting and (2) photophobia and phonophobia.


MacGregor EA. Migraine. Ann Intern Med. 2017 Apr 4;166(7):ITC49-ITC64. [PMID: 28384749] doi:10.7326/AITC201704040

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