A 13-year-old girl presents to her pediatrician and reports having debilitating headaches every few weeks for the past 6 months. In each episode, the patient describes feeling tired and having blurry vision the day before the headache. Onset is gradual over the next 24 hours, but when the throbbing, pulsating pain begins, the patient is quickly debilitated. Pain has been both unilateral and bilateral and occurs in the frontotemporal region. She experiences severe nausea, has vomited on three occasions, and needs to quickly move to a quiet, dark room to sleep for several hours. Her headaches typically last for 24 hours. Nonsteroidal anti-inflammatory drugs have been ineffective.

The patient's mother reports that the headaches are usually precipitated by physical activity (she is on several sports teams at school) and occur several days before the arrival of her period, consistently each month. She began menstruating 1 year ago, at age 12 years.

Physical exam reveals nothing remarkable. Neurologic exam is negative for any focal neurologic abnormalities. The patient is 5 ft 5 in with a body mass index of 22. Vitals are normal. There is no evidence of lymph node or ophthalmic abnormalities nor cranial/cervical muscle tenderness. She does not have any known comorbidities. Her mother reports experiencing the same types of headaches at this age, which she said had resolved after she had her daughter at age 28 years.