BACKGROUND
A 40-year-old right-handed white woman presents to her primary care physician because of left-sided numbness and weakness that occurred 3 days ago. The episode lasted 6 hours and was associated with her typical left-sided migraine headache, with photophobia, nausea, and vomiting. The numbness and weakness preceded the headache by 3 hours. The patient reports that, 3 hours after the onset of the headache, she was able to sleep for 8 hours. When she awakened, the headache and associated symptoms had resolved. The patient reports that she has run out of her usual triptan migraine-abortive medication, a 5-HT1 receptor agonist, and that she wants a refill for her prescription. This is her third migraine in the past 2 months. Nonenhanced brain CT findings obtained 15 years ago were normal.
On further questioning, the patient denies any similar episodes in the past and states the only symptoms associated with her migraines had been visual in nature. Her medical history is otherwise unremarkable except for an appendectomy at 15 years of age and 3 uncomplicated pregnancies. Her youngest child is 13 months old. She does not smoke cigarettes or drink caffeinated beverages. Her only medications are a multivitamin and her triptan medication. She has never taken migraine prophylactic agents.
Findings from the patient's general physical and neurologic examinations are normal.
What is the most appropriate course of action? - Refill the current prescription for a triptan abortive medication and review its proper use with the patient.
- Initiate therapy with prophylactic migraine medication in conjunction with the triptan abortive medication.
- Completely review this patient's case and consider further diagnostic studies before prescribing further migraine therapy.
- Refer the patient to a neurologist.
- Both C and D are correct.
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Hint
This is not your run-of-the-mill migraine headache.
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Author:
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Agapito S. Lorenzo, MD
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Associate Professor, University of Nebraska and Creighton University, Departments of Neurology
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eMedicine Editor:
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Nicholas Lorenzo, MD
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Consulting Neurologist, Chief Editor, eMedicine Neurology
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eMedicine Case
