BACKGROUND
A 43-year-old right-handed white man presents to his primary care physician because of headaches. He states that the headaches began 2.5 months ago at a frequency of every other week, although the last 2 were separated by only 8 days. The most recent headache occurred 3 days ago. He describes the headaches as throbbing; usually right sided; and associated with photophobia, nausea, and vomiting. He denies any visual changes, aura, or prodrome associated with the headaches. He also denies any sensory, motor, or visual changes. The patient reports that the headaches resolve when he is able to sleep. The patient asks about migraine therapy and wonders whether he is a candidate for one of the new triptan medications he is hearing so much about in the lay press.
On further questioning, the patient reports that he had migraine headaches as a teenager; these were identical to the current headaches. Twenty-five years ago, he underwent a complete workup, and nonenhanced brain CT findings were negative. At that time, he was treated with both prophylactic and abortive migraine medications, with varying success. His last migraine headache prior to the one 3 months ago occurred when he was 25 years of age. His medical and surgical histories are otherwise negative. He is not taking any medications except for minimal doses of over-the-counter (OTC) ibuprofen during his last 2 headaches; however, these were not effective. The patient does not smoke cigarettes or drink caffeinated beverages.
Findings from the patient's general physical and screening neurologic examinations are normal.
What is the most appropriate course of action? - Prescribe triptan abortive medication and review its proper use with the patient.
- Start prophylactic migraine medication in conjunction with 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
Headache classification is critical to this diagnosis.
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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
