Case Study: When a "Migraine" Wasn't Just a Migraine

Background

Headaches are among the most common neurological complaints encountered in healthcare. While the majority represent primary headache disorders such as migraine or tension-type headaches, persistent symptoms that fail to respond to appropriate management should prompt clinicians to reconsider the working diagnosis.

This observational case demonstrates the importance of recognising atypical clinical features, maintaining a broad differential diagnosis, and facilitating appropriate medical referral when the presentation extends beyond a routine musculoskeletal or headache disorder.

Patient Presentation

A woman in her late forties presented to the clinic seeking another opinion after several years of debilitating migraine-like headaches.

The patient described severe headaches reaching 8–9/10 on the Visual Analogue Scale (VAS). The pain was characterised as deep, throbbing, dull, aching, and associated with an intense sensation of pressure.

The episodes significantly affected her quality of life and were accompanied by:

• Severe fatigue

• Visual disturbances

• Sound sensitivity (phonophobia)

• Episodes of elevated blood pressure during severe attacks

• Recurrent hospital admissions over several years

The patient explained that the severity of the headaches had significantly affected both her personal and professional life, with episodes becoming so disabling that maintaining normal daily activities had become increasingly difficult.

Previous Management

Before attending our clinic, the patient had pursued numerous treatment approaches.

These included conventional medical management, complementary therapies, allied health interventions, homeopathic treatments, and various conservative approaches.

Despite these efforts, the headaches continued to recur with minimal long-term improvement.

The patient attended our clinic hoping to determine whether another explanation for her symptoms might exist.

Initial Assessment

A comprehensive history and physical examination were performed.

A trial of conservative care was provided during the initial consultation with the aim of determining whether a musculoskeletal component was contributing to the patient's presentation.

The patient reported temporary improvement on the day of treatment. However, the headaches returned during work the following day, suggesting that the underlying presentation was unlikely to be explained by a routine mechanical headache alone.

The patient subsequently returned during a milder episode for further assessment.

Clinical Reassessment

Following reassessment, the overall presentation appeared inconsistent with a typical cervicogenic headache or uncomplicated migraine.

Several aspects of the patient's history, symptom behaviour, prolonged clinical course, and lack of sustained response to previous therapies prompted consideration that additional medical causes should be investigated.

Rather than continuing repeated conservative treatment, the consultation shifted towards identifying possible differential diagnoses and facilitating further medical assessment.

Clinical Decision-Making and Referral

A detailed referral letter was prepared outlining the clinical observations and concerns identified during assessment.

The referral was intended to assist the treating medical team by communicating why the presentation appeared atypical and why additional investigation was considered appropriate.

Based on the patient's history and examination findings, the referral suggested that the treating clinicians consider further evaluation for possible inflammatory or vascular causes if these remained consistent with their own clinical assessment.

Clinical considerations documented within the referral included the possible value of inflammatory blood investigations, such as Erythrocyte Sedimentation Rate (ESR) and C-Reactive Protein (CRP), together with additional investigations or vascular imaging if considered appropriate by the treating medical specialists.

These suggestions were not intended to establish a diagnosis or direct medical management, but rather to communicate the clinical reasoning that prompted referral and to support multidisciplinary collaboration.

The patient was also advised that, if possible, medical assessment during an active or recently active episode might assist the treating team in obtaining additional clinically relevant information.

Follow-Up Outcome

Approximately two weeks after referral, follow-up contact was made with the patient.

She reported that subsequent hospital assessment, specialist evaluation, and further investigations had established a diagnosis of Giant Cell Arteritis (Temporal Arteritis).

Appropriate medical treatment was initiated under specialist care following confirmation of the diagnosis.

Although Giant Cell Arteritis most commonly affects adults over 50 years of age, less common presentations may occur in younger individuals, emphasising the importance of considering atypical diagnoses when the overall clinical picture does not align with more common headache disorders.

Understanding Giant Cell Arteritis

Giant Cell Arteritis (GCA) is a form of large-vessel vasculitis characterised by inflammation affecting medium and large arteries, particularly those supplying the head and neck.

Early recognition is important because untreated disease may lead to serious complications, including permanent visual loss and other vascular complications.

Management is undertaken by medical specialists and commonly involves corticosteroid therapy together with additional immunomodulatory medications where clinically appropriate.

Clinical Reflection

One of the most important responsibilities in musculoskeletal practice is recognising when a patient's presentation extends beyond the expected pattern of a routine mechanical disorder.

Not every severe headache represents a primary migraine disorder.

When symptoms persist despite multiple treatment approaches, or when the clinical presentation becomes increasingly atypical, clinicians should remain willing to broaden the differential diagnosis and facilitate further medical investigation.

The role of the chiropractor in this case was not to diagnose Giant Cell Arteritis, but to recognise concerning clinical features, appreciate the limitations of conservative care, and recommend timely medical assessment.

Key Clinical Lessons

• Persistent headaches that fail to respond to appropriate management should be carefully reassessed.

• Atypical clinical presentations warrant consideration of broader differential diagnoses.

• Appropriate referral is an important component of evidence-informed musculoskeletal practice.

• Communication between healthcare professionals can support timely investigation and continuity of patient care.

• Recognising clinical limitations is an essential aspect of safe, patient-centred healthcare.

Professional Note

The investigations discussed in this case reflect the clinical reasoning documented within a referral prepared for one individual patient. They were provided to assist communication with the treating medical team and should not be interpreted as a universal diagnostic protocol.

Selection of investigations, interpretation of results, and establishment of a diagnosis remain the responsibility of the treating medical specialists and should always be based on the individual patient's presentation and current clinical guidelines.

Important Disclaimer

This anonymised observational case is presented for educational purposes only.

The diagnosis of Giant Cell Arteritis (Temporal Arteritis) was established following subsequent hospital investigation and specialist assessment. The chiropractor's role was limited to recognising atypical clinical features, documenting clinical concerns, and facilitating appropriate medical referral.

This case should not be interpreted as medical advice. Most headaches are not caused by Giant Cell Arteritis, and similar symptoms may have many different causes. Individuals experiencing persistent, severe, or progressively worsening headaches—particularly when associated with visual symptoms, jaw pain, scalp tenderness, fever, or other concerning neurological features—should seek prompt medical assessment.