A 58-year-old postmenopausal woman presents to her primary care physician complaining of debilitating headaches. She has had five of these episodes in the past 6 months, which she describes as throbbing pain in the frontotemporal and ocular area of the head that gradually worsens over a period of several hours. During this time, she also experiences severe nausea as well as photo- and phonophobia. She has vomited during two of the five episodes. She reports neck and shoulder pain and stiffness the day before the onset of the headache, which worsens and continues during the episode. She does not report any visual, sensory, or motor symptoms. Her headaches typically last 12-24 hours. She has used nonsteroidal anti-inflammatory drugs to try to control the pain, to no avail. She reports that lying down in a quiet, dark room and sleeping for several hours is the only thing that helps her, as well as remaining hydrated as best as possible.

The patient also reports having increased vasomotor symptoms associated with menopause in the form of hot flashes and night sweats in the past year and a half that have become increasingly more bothersome. She is not a candidate for hormonal replacement therapy.

The physical exam reveals nothing remarkable, except that the patient appears tired and pale.

The neurologic exam is normal, negative for any focal neurologic abnormalities. Heart, lung, and breath sounds are normal on auscultation, blood pressure is normal (120/75 mm Hg), liver and spleen are normal on palpation. There is no evidence of lymphadenopathy, ophthalmic abnormalities, or cranial/cervical muscle tenderness.