The patient has migraine with aura and should be given sumatriptan. The pattern of his headaches has been stable for more than a decade and meets diagnostic criteria for migraine, namely, that migraine attacks should last between 4 and 72 hours if untreated, and the pain must possess two of the following four features: unilateral location, throbbing nature, moderate or severe intensity, and aggravation with physical activity. The quality and duration of the episodic visual distortion are compatible with migraine aura. Aura occurs in 25% to 35% of those with migraine and, most commonly, is visual. By definition, migraine aura should last between 5 and 60 minutes with complete resolution. Symptoms often precede headache but may accompany or even occur separately from the pain of an attack. Episodes of hemisensory symptoms or language disturbance of a similar duration are also described as “typical” aura and warrant no specific restrictions or acute migraine therapy. Because of their lower cost, NSAIDs are considered first-line options in acute migraine management. Because this patient has not responded to NSAIDs, acute treatment with a triptan is now appropriate.
CT of the head and MRI of the brain may be appropriate in the setting of potential secondary headache, but this patient has no “red flags” raising concern for this type of headache and instead exhibits classic signs and symptoms of migraine with aura. The headache pattern is stable, the visual loss is periodic and always reversible over the course of many years, and both headache and visual loss meet diagnostic criteria for migraine with aura. Neuroimaging is inappropriate in the evaluation of uncomplicated headache.
Similarly, electroencephalography has no role in the assessment of headache disorders, according to the American Academy of Neurology's five “Choosing Wisely” initiatives. Compared with standard clinical evaluation, it offers no diagnostic advantage, does not improve outcomes, and adds to medical costs.
Measurement of the erythrocyte sedimentation rate would be reasonable in the setting of suspected temporal arteritis. However, the young age of this patient and stable migraine pattern—episodic headaches with occasional transient visual impairment over 18 years—are incompatible with this diagnosis. Visual loss that occurs with temporal arteritis is typically monocular and more compatible with ischemic events, such as amaurosis fugax. Although the visual loss in typical migraine aura is benign and fully reversible, that noted with temporal arteritis is concerning and may become permanent following retinal artery occlusion.