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An evolving headache
  1. M Simpson1,
  2. C Duncan2,
  3. R Knight3,4,
  4. M W J Strachan5
  1. 1
    Senior House Officer in Neurology
  2. 2
    Specialist Registrar in Neurology
  3. 3
    Consultant Neurologist
  4. 4
    Department of Clinical Neurosciences, Western General Hospital, Edinburgh, UK
  5. 5
    Consultant Endocrinologist, Metabolic Unit, Western General Hospital, Edinburgh, UK
  1. Dr M Simpson, Department of Neurology, Western General Hospital, Edinburgh EH4 2XU, UK; marion.simpson{at}

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A 42-year-old taxi driver was referred with a one-year history of headache. He was otherwise well with no significant past medical history and no other symptoms on systemic enquiry. He smoked 20 cigarettes per day. He described episodic headaches, occurring 2–3 times each week. Most were mild and responded readily to paracetamol. He described a typical headache as a throbbing pain, which started bifrontally and then spread to involve his whole head. Occasionally, he had a similar but more severe headache, associated with nausea, vomiting, photophobia and blurred vision: “the big one”. Neurological examination, including fundoscopy, visual fields and visual acuities was normal. General examination was also normal and his blood pressure was 110/76.

Question 1

What is the diagnosis?


Headache is very common, affecting most people at some point in their lives. It is also one of the commonest presenting complaints in general neurology out-patient clinics. The history is the key to classifying primary headache and identifying secondary headaches (due to underlying structural brain lesions). Secondary headache is, however, relatively rare and the majority of patients seen in both general practice and neurology out-patient clinics have primary headache.1, 2 On the basis of his occasional severe headaches, the patient fulfilled the International Headache Society criteria for migraine without aura.3 The milder frequent headaches were also likely to be migraine although they did not fulfil the strict criteria for migraine or probable migraine. In clinical practice, however, patients with migraine relatively frequently have some headaches that do not meet the strict diagnostic criteria, intermixed with their more defined migraine episodes. The headaches were intermittent with a pattern that was stable over one year, and there were no features of any other disorder, with a normal clinical examination.

Question 2

Does he require brain imaging?


No. In patients with stable episodic headache, …

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