ICHD-3: The Trilogy
A 42-year-old veteran presents with bilateral, non-pulsating headache of mild-to-moderate intensity lasting 2 hours. She denies nausea, vomiting, photophobia, and phonophobia. What is the most likely primary headache diagnosis?
Tension-type headache
A 72-year-old veteran presents with new-onset headache, jaw claudication, and visual disturbance. What diagnosis must not be missed?
Giant cell (temporal) arteritis
According to the 2025 ACP guidelines, what is the first-line acute treatment for moderate-to-severe episodic migraine that provides the greatest net benefit?
Combination therapy with a triptan and an NSAID (e.g., sumatriptan + naproxen)
According to the 2025 ACP guidelines, name three first-line preventive medications for episodic migraine.
Beta-blockers (metoprolol or propranolol), valproate, venlafaxine, or amitriptyline
A 65-year-old veteran with migraine has well-controlled hypertension and no history of cardiovascular disease. Can you prescribe a triptan?
Yes, after careful screening for cardiovascular/cerebrovascular disease and checking risk factors (LDL, blood sugar, blood pressure), with annual monitoring
A 35-year-old male veteran describes severe left orbital pain lasting 90 minutes, occurring twice daily for the past 3 weeks. During attacks, he paces around the room and has left-sided tearing and nasal congestion. What primary headache disorder is this, and what distinguishes it from migraine?
Cluster headache. It is distinguished by strictly unilateral pain with ipsilateral autonomic features (lacrimation, rhinorrhea, conjunctival injection) and restlessness/agitation, whereas migraine typically causes patients to seek a quiet, dark room and rest.
Name three "red flag" features that should prompt evaluation for secondary headache.
Systemic symptoms (fever), neurologic deficit, sudden/thunderclap onset, older age at onset (>50 years), pattern change, positional headache, progressive symptoms, papilledema, pregnancy/postpartum, painful eye with autonomic features, post-traumatic onset, pathology of immune system, or painkiller overuse
A patient takes ibuprofen 400 mg for mild migraine attacks. What is the evidence-based dose range for NSAIDs in acute migraine treatment?
Aspirin 500-1000 mg (risk of gastric irritation), ibuprofen 400-800 mg, or naproxen 500-550 mg (but 825 mg may be slightly more effective)
A 32-year-old female veteran with migraine and hypertension wants to start preventive therapy. Which medication class addresses both conditions?
Beta-blockers (propranolol, metoprolol) or angiotensin receptor blockers (candesartan)
Name three absolute contraindications to triptan use.
Coronary artery disease, prior MI or stroke, cerebrovascular disease, peripheral vascular disease, uncontrolled hypertension
A patient reports headaches occurring 18 days per month for the past 4 months. On 10 of those days, headaches are unilateral, throbbing, with nausea and photophobia. On the remaining 8 days, headaches are bilateral and mild without associated symptoms. How would you classify this patient's headache disorder?
Chronic migraine. The patient has headaches ≥15 days per month for >3 months, with ≥8 days meeting migraine criteria.
https://www.healthquality.va.gov/guidelines/pain/headache/VA-DOD-CPG-Headache-Full-CPG.pdf
A 55-year-old veteran with no headache history presents with sudden-onset severe headache that reached maximal intensity within 60 seconds. What is the most concerning diagnosis, and what is the next step?
Subarachnoid hemorrhage, and ED referral for emergent neuroimaging (CT head)
Your patient with migraine has coronary artery disease and prior MI. Which acute migraine-specific medications are safe alternatives to triptans?
CGRP inhibitors aka gepants (ubrogepant, rimegepant, zavegepant) or ditans (lasmiditan), which are not vasoconstrictive
Your patient failed trials of propranolol and amitriptyline. According to ACP 2025 guidelines, what medication class should be offered next?
CGRP antagonists (gepants: atogepant or rimegepant) or CGRP monoclonal antibodies (eptinezumab, erenumab, fremanezumab, galcanezumab)
A 29-year-old female veteran with episodic migraine is planning pregnancy. Which preventive medications are contraindicated, and what are safer alternatives?
Contraindicated: valproate and topiramate (teratogenic)
Safer alternatives include: propranolol, metoprolol, or non-pharmacologic approaches (biofeedback, cognitive behavioral therapy, exercise)
A 28-year-old veteran describes recurrent headaches with unilateral throbbing pain, moderate intensity, photophobia, and phonophobia, but denies nausea or vomiting. According to ICHD-3 criteria, she fulfills all but one criterion for migraine. What is the appropriate diagnosis and management approach?
Probable migraine. The VA/DoD guidelines recommend not withholding therapy when patients don't meet all criteria, and empiric treatment for probable migraine should be considered. Treatment should proceed as for definite migraine, with continual reassessment during therapy.
How do you differentiate migraine aura from transient ischemic attack based on symptom onset and character?
Migraine aura develops gradually over minutes with typically positive symptoms (scintillations, paresthesias), while TIA has sudden onset (within seconds) with typically negative symptoms (neurological deficits)
A patient reports that oral sumatriptan "doesn't work." Name three reasons for triptan failure and two strategies to improve efficacy.
Underdosing, delayed administration, or gastroparesis/poor absorption. Strategies include taking earlier in attack, trying a different triptan, using non-oral formulation (nasal spray, subcutaneous), or adding an NSAID.
A 38-year-old female veteran with chronic migraine (20 headache days/month) has failed multiple oral preventives. What injectable preventive therapy is FDA-approved specifically for chronic migraine?
OnabotulinumtoxinA (Botox), administered as 31 injections in 7 head/neck muscle sites every 12 weeks
A patient has been taking sumatriptan 100 mg daily for the past 3 months for frequent headaches. What diagnosis should you consider, and what is the management?
Medication overuse headache (using acute migraine medication ≥10 days/month for ≥3 months). Management includes withdrawal of the overused medication, bridge therapy (short course of steroids or alternative acute treatment), and initiation of preventive therapy.
Compare the typical duration and frequency patterns that distinguish cluster headache from migraine and tension-type headache.
Cluster headache lasts 15-180 minutes and occurs up to 8 times daily, migraine lasts 4-72 hours with variable frequency, and TTH can last 30 minutes to 7 days.
A 28-year-old veteran with known migraine presents with a new pattern: headaches are now always on the right side, progressively worsening over 6 weeks, and associated with morning vomiting. What could these symptoms suggest, and what is your next step?
Morning vomiting may suggest increased intracranial pressure, and neuroimaging (MRI brain preferred)
A 45-year-old veteran takes sertraline 100 mg daily for depression. She asks about starting a triptan for migraine. What is the theoretical drug interaction, and is it a contraindication?
Serotonin syndrome (theoretical concern with triptans + SSRIs/SNRIs/TCAs), but it is not an absolute contraindication and the combination is commonly used safely in clinical practice
https://jamanetwork.com/journals/jamaneurology/fullarticle/2673391
A patient asks about topiramate for migraine prevention. Name two common adverse effects and one absolute contraindication.
Adverse effects: sedation, slow cognition, kidney stones, skinny (weight loss), sight threatened (glaucoma), speech (word-finding) difficulties
Absolute contraindication: pregnancy (teratogenic)
A 58-year-old veteran presents with new-onset migraine with aura. He has no prior headache history. What are three important differential diagnoses to consider, and what workup is indicated?
Stroke/TIA, intracranial mass lesion, or other cerebrovascular disease (arteriovenous malformation, arterial dissection).
Workup includes neuroimaging (MRI brain preferred), and consider vascular imaging if high suspicion for cerebrovascular disease.