A 25-year-old white woman presents to your office for an annual examination. She is a G2P2 and had a bilateral tubal ligation after her last child was born (3 years ago). Her menstrual periods are regular; her LMP was 2 weeks before her visit. On review of systems she describes two to three headaches per month for the past year, usually unilateral and occasionally associated with nausea. The headaches last for several hours. She denies visual changes or other neurological changes when the headaches occur. She had migraine headaches in high school, but they stopped when she was about 20. She has not noted that foods, alcohol, stress, or fatigue trigger the headaches. Her headaches usually happen within the same several-day period and are not spread out over the month. Her last bout with the headaches occurred about 2 1 /2 weeks ago.
What is the most likely diagnosis?
A. Tension headacheThis patient’s headache pattern is typical of menstrual migraines, occurring within several days of menses. She denies that fatigue or stress contributes to the headache; therefore, tension headache is not likely. She has no aura associated with the headache; therefore, classic migraine (migraine with aura) is not correct. Sinus headaches would not occur cyclically. Cluster headaches tend to occur in brief, sharp bursts and are more common in men than women. Migraine is precipitated by menstruation in 24% to 68% of women. Although this patient’s history points to menstrual migraine, before initiating treatment a headache diary should be recorded for 2 to 3 months to ensure that the migraines occur exclusively or primarily within 3 days of the onset of menses.