A 47-year-old woman complains of severe headaches that involve only the right orbital, temporal, and occipital areas. She describes the pain as sharp and stabbing, and she rates its severity as 9 or 10 on a 10-point visual analog scale. The headaches last an average of 15 to 30 minutes and usually occur daily. She may have as many as 6 attacks a day; occasionally they also occur at night, waking her. The longer and more severe attacks can be disabling; however, between attacks, she is usually headache-free and functions normally.
The headaches are associated with right-sided lacrimation, nasal congestion, and conjunctival injection. The patient thinks she may also have some associated hypersensitivity to bright light, but she does not have nausea. Except for the unilateral autonomic features of her headache attacks, results of a physical and neurological examination are normal. An MRI scan of the brain, performed 2 weeks earlier, was also normal.
The patient has tried various pain medications, including over-the-counter agents, such as ibuprofen; highly potent prescription painkillers, such as butalbital, codeine, propoxyphene, and hydrocodone; a variety of triptans (sumatriptan, zolmitriptan, frovatriptan, eletriptan, and naratriptan); and most recently, dihydroergotamine mesylate (DHE) nasal spray. She has been hospitalized 3 times in the past 2 years; during each hospitalization, she was treated with intravenous DHE every 8 hours (9 doses total) in combination with various NSAIDs. None of these agents have produced significant and stable positive results.
This patient began having headaches 7 years earlier. At first they occurred on an irregular, infrequent basis, then they gradually worsened. Migraine was diagnosed in the patient's mother when the mother was in her late 20s; the attacks resolved with menopause.
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