A 14-year-old girl came to the office because of permanent and refractory headaches. She was symptom-free until the age of 12, when she started suffering from occasional headache attacks, some of them preceded by syncope. The first spell occurred at an airport toilet just prior to a family trip, during which no abnormality was present. However, attacks increased to 4–5 per week right after returning to town, precluding her from attending school. The present frequency of faints is around twice a month.

The headache was described as extremely intense, holocranial and pulsating, accompanied by nausea, photophobia and phonophobia. Short-lasting photopsias consisting of tiny flashing bright spots scattered throughout the entire visual field may be present on rare attacks, as well as paraesthesia at the right arm and motor aphasia. The headache frequency was initially low but became continuous 1 year ago. Symptoms included paroxysmal tremor in both legs, gait instability, hair loss, distractibility, fatigue, dysuria and diarrhoea (twice a month). She could not identify any trigger or aggravating factors. Menarche and thelarche occurred at the age of 11. Menses were all accompanied by excruciatingly severe dysmenorrhoea. She denied having sexual intercourses and drug abuse of any kind, except for prescribed medicines. Her mother referred occasional unilateral headaches, her grandmother had a history of depression, and an uncle from the father’s side was crack and cannabis addicted.

Regardless the innumerable physicians she visited including neurologists, dentists, ophthalmologists and otorhinolaryngologists, the disease progressed all the same. Several MRI and CT scans, a lumbar puncture, tilt-table testing, ECG and blood samples were normal. She missed school for 6 months because of the pain and was admitted on several occasions to different hospitals for up to once a week. Her parents showed a list of 32 medicines used either alone or in combination to reduce pain. For the last 6 months, she was under 1,000 mg divalproate together with 10 mg atenolol, 40 mg amitriptyline, 2.5 mg tizaninide, 5 mg flunarizine, 20 mg pyridoxine, 20 mg riboflavin, 100 mg tryptophan, 100 mg coenzyme Q₁₀ and 150 mg feverfew on a daily basis, with a combination of naratriptan, domperidone and celecoxib as acute medicines. Her general and neurological examinations were normal. The blood pressure was 100/70 mmHg and the heart rate was 72 bpm.

Despite the fact that she considered her life miserable, the pain unbearable and the medications hopeless, she was particularly unconcerned during the interview. It became obvious that the triviality in her speech and behaviour were completely incompatible with the seriousness of her disease. In a second interview she admitted that, simultaneously with the beginning of her symptoms, the family was “forced” to move due to an accident suffered by her father. “Because of that, he could no longer take care of a house with a backyard and garden”, she said. Since she loved her house, school, friends and the neighbourhood, she “became enraged but had no courage to tell anyone”. When asked why she did not share her feelings with her family, she answered, “it was not fair with my father, it was not his fault after all”. She then tried to deliberately boycott the school but “did not succeed having marks low enough to get held back”. However, because of the excessive nonattendances, she had to change to a new school. During holidays the symptoms always tend to decrease almost completely, the maximum severity occurring at the start of a new school term.

The case history represents the most relevant source of information for headache diagnosis, and this patient is no exception. First, distinguishing between a primary and a secondary disorder is mandatory. The age of onset, normal physical examination, innocuous previous neuroimaging and lack of red flags are the four elements that strongly indicate the presence of a primary headache in this case. Second, the clinical profile must be analysed for a proper diagnosis. Are there features that suggest a particular primary headache? The diagnoses of migraine without aura, migraine with aura and chronic migraine are possible, but a headache diagnosis does not rule out other concomitant disorders.

Considering the faints, signs and symptoms allowing the distinction between seizure, vertigo and vestibular dysfunctions must be investigated. The clinical picture usually suffices for the diagnosis. Seizures may involve suddenness, jerks, postictal confusion, incontinence, lateral tongue bites and slow recovery. Vertigo is characterized by a feeling that surroundings are turning or spinning, which tends to aggravate with head movements. Syncope has a more gradual onset as compared with seizure, tends to last less and has a quicker recovery and may occur at upright position, not infrequently at the bathroom. The physical examination must include blood pressure and heart rate in supine, sitting and standing positions and careful examination of eye movements and eyelids, vestibuloocular reflexes and vestibulospinal reflexes. A tilt-table test, an ECG and a cardiological workup are necessary. The possibility of psychogenic syncope is considered if no cause is found. Some migraine patients are particularly prone to syncope without any other precipitating factor.