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To the Editor: In their Rational Clinical Examination article, Mr Detsky and colleagues¹ evaluated the usefulness of the history and physical examination to determine whether a patient has migraine or some other condition requiring neuroimaging for diagnosis. I agree that patients with migraine do not ordinarily require neuroimaging. However, it is also important to consider that neuroimaging will not always define the illness in patients with other serious types of headache.

In patients older than 50 years with new-onset headache, particularly if there is tenderness of the scalp or head, tests such as measurement of erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) level should be performed to assess for possible giant cell or temporal arteritis. In the presence of this disease, the ESR is usually greater than 50 mm/h and may exceed 100 mm/h, but even if the ESR is 20 to 40 mm/h, giant cell arteritis is still . . . [Full Text of this Article]

Steven Brenner, MD
sbren20979@aol.com
Department of Neurology
St Louis Veterans Administration Medical Center
St Louis, Mo

RELATED LETTER

Does This Patient Have a Migraine?—Reply
Michael E. Detsky, Devon R. McDonald, and Christopher M. Booth
JAMA. 2007;297(1):42.
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