A 59-year-old woman referred by a neurologist to the Danish Headache Center, a tertiary headache centre, for the treatment of refractory migraine presents for the initial consultation. The patient has suffered from frequent headaches since childhood and in the last couple of years from daily headaches. She told me that she was so tired of the headaches that have ruined her life and of all the various treatments she has received during her life. None of the treatments has had any effect, several have been costly and several had bothersome side effects. She had almost given up hope. The patient did not fill out the 4-week headache diary that has been mailed to her from the headache centre prior to the initial consultation, and it was difficult for her to give a detailed headache history. She reported that her headaches could be unilateral or bilateral, of moderate to severe intensity, throbbing and at times pressing in character and could be aggravated by waking stairs. She also reports frequent nausea and sometimes sensitivity to sounds and light. The headaches are clearly provoked by psychological stress and to a lesser extent by physical activity. Sometimes headaches are preceded by visual disturbances. She had been on sick leave due to the headaches in the past 3 months. She reports being often anxious but she denies depressed mood. She works as a teacher and had some stress at work. Otherwise, she is healthy. Her mother had suffered from life-long migraines. Her paternal uncle had brain aneurysm. At the first consultation, it was obvious that the patient suffered from migraine, tension-type headache (TTH) and anxiety on the most severe headache days. General and neurological examination demonstrates increased pericranial myofascial tenderness. Her blood pressure and pulse are within normal limits. Electrocardiogram and routine blood tests are unremarkable. What to do for this severely incapacitated woman?

The major diagnostic problem in this case is differentiation between episodes of tension-type headache and migraine. In the general population, 94 % of migraineurs also experience TTH and 56 % of migraineurs experience frequent episodic TTH. In contrast, TTH occurs with similar prevalence in those with and without migraine. However, the majority of patients seen by headache specialists will suffer from both disorders. Due to lack of accompanying symptoms and the relatively milder pain intensity in TTH, patients rarely complain of severe incapacitation due to their pain. TTH is the most featureless of the primary headaches and because many secondary headaches may mimic TTH, a diagnosis of TTH should be made only after exclusion of other organic disorders.

A general and neurological examination and prospective follow-up using a headache diary for at least 4 weeks in which all drugs taken are recorded are essential to make the diagnosis. The diary may also reveal triggers of headache and medication overuse, and it will establish the baseline against which to measure the efficacy of treatments. Identification of a high intake of analgesics is important because medication overuse requires specific treatment. There are no reliable imaging or laboratory tests that are reliably useful in the differential diagnosis. Manual palpation of the pericranial muscles and their insertions should be done to demonstrate a possible muscular factor for the patient and to plan the treatment strategy, where physical training and biofeedback/relaxation therapy are important treatment modalities. Paraclinical investigations, in particular brain imaging, are necessary if secondary headache is suspected (e.g. the headache characteristics are atypical), if the course of headache attacks changes or if persistent neurological or psychopathological abnormalities are present.

At the first consultation, the patient was informed about general aspects of headaches such as basic knowledge about pathophysiological mechanisms and common trigger factors, and she was instructed how to fill out a 4-week headache diary. At follow-up after 4 months (shorter would have been optimal but was not possible due to workload in the centre), the diary demonstrated that the most frequent headache was located bilaterally and the character was pressing and intensity moderate with no worsening with physical activities. There occasionally was phonophobia but no accompanying photophobia or nausea. Two days per month, she had unilateral, severe, throbbing headaches with aggravation during physical activity and concomitant nausea and photo- and phonophobia. Approximately two times per year, she experienced scintillating scotomas lasting 30 min which sometimes were followed by headache within 15 min. It was now clear that she suffered from chronic tension-type headache 28 days per month, migraine without aura 2 days per month and infrequent attacks of migraine with visual aura. She was also suffering from anxiety but this was only in relation to her migraine attacks. Both TTH and migraines were provoked by psychological stress. There was no acute medication overuse.

The patient had been treated by her general practitioners since childhood, by a dentist and by three different neurologists for her headaches all without any effect on her headache. Previous non-pharmacological therapies included relaxation therapies, physical therapies, acupuncture, chiropractor and numerous alternative therapies. Among these, only relaxation therapy had had a minor effect. Previous attack medications included aspirin, several NSAIDs, paracetamol and triptans. Previous prophylactic treatments included metoprolol 100 mg daily and others that she did not remember. At the time of referral, she was using ibuprofen 200–600 mg per day approximately 8 days per month and amitriptyline 10 mg daily. At the first consultation in the headache centre, the patient was referred to the psychologists and the physical therapists in the headache centre with the aim of a stress and management course (cognitive-behavioural therapy) and physical therapy with focus on the improvement of posture, individual exercise programmes, relaxation and biofeedback. She was prescribed sumatriptan for migraine attacks and candesartan for migraine prophylaxis.