Migraine

The vast majority of patients presenting with headache and no physical signs will have migraine, or, less commonly, a variant such as cluster headache. Some migraine patients will have a typical visual, sensory, or speech aura, while others will have less clear-cut premonitory symptoms. A careful history will establish whether there are any atypical features that might warrant further investigation and/or suggest an alternative diagnosis. It is essential that the initial assessment ascertains the frequency and severity of the attacks, as this will determine whether analgesic or prophylactic treatment or both should be offered. The patient’s previous medication should be recorded, noting the largest doses given and the reason why each had been discontinued. Many will be overusing analgesics, particularly opiates, and these can easily lead directly to a chronic drug-induced headache. The real skill in headache management is ensuring that the patient’s history is fully and accurately recorded.