Migrainelike Headache in a Patient With a Hemorrhagic Pituitary Macroadenoma

Abstract

A 23-year-old woman presented with a 4-day history of a severe migrainelike headache with a normal neurologica examination. The headache resolved after a ketorolac injection, but recurred a few hours later. An MRI scan of the brain showed a hemorrhagic pituitary macroadenoma for which she underwent transsphenoidal removal of the tumor 1 month later. Although uncommon, pituitary hemorrhage with and without apoplexy should be considered in the differential diagnosis of acute headache. Pituitary hemorrhage can be routinely identified on an MRI scan even without pituitary views. However, the pathology can be overlooked and underimaged on a CT scan for acute headache using 10-mm and even 5-mm slices.

Favorable Response to Analgesics Does Not Predict a Benign Etiology of Headache

“…Seven of the 18 studies found that 46/103 patients (44%) described a significant or complete resolution of HA from medications such as anti‐emetics and nonsteroidal anti‐inflammatory drugs (NSAIDs) (Table 1). Five were case reports 14‐18 . Two articles, one retrospective and the other prospective, described relief of HA from simple or common analgesics 19,20 .…”

“…In all the studies, the HAs had secondary causes including subarachnoid hemorrhage (SAH), subdural hematoma, intracranial hemorrhage, meningitis, cerebral venous sinus thrombosis (CVST), pituitary adenoma, and brain tumor. In 4 of the studies, 7 patients had a delay in the real diagnosis by hours to weeks, at least in part, because of a misinterpretation of the favorable response to analgesics 14‐16,18 …”

Pituitary Apoplexy Presenting as Status Migrainosus

“…There have been a few other cases of pituitary apoplexy that presented with migraine like headache, including ophthalmoplegic migraine like headache . Evans, in 1997, also described a 23‐year‐old woman with a 4‐day history of severe migraine‐like headache who had similar MRI findings of a hemorrhagic pituitary microadenoma …”

Benign or Sinister? Distinguishing Migraine From Subarachnoid Hemorrhage

“…Whether patients with first time migraine need investigation can only be answered with the rather unhelpful “it depends.” A confident diagnosis (as here) does not warrant investigation, but more abrupt presentations (“crash migraine”) certainly do, as we know clinical features alone are insufficient to help us differentiate the benign from the sinister in acute onset headache syndromes, 3 and that some rare pathologies may mimic migraine 10 . Similarly, the presence of focal neurological symptoms/signs, unless very typically of an evolving migrainous nature, are likely to trigger at least a brain scan.…”