SSRIs and Triptans: Safe as Combination Therapy?February 1st 2008
Depression was diagnosed 6 years earlier in a 37-year-old woman; it has been successfully managed since then with fluoxetine and outpatient psychotherapy. Since her teenage years, the patient has also experienced sporadic (fewer than 3 or 4 per year) mild or occasionally severe headaches, which she has usually self-treated with over-thecounter (OTC) agents or "just slept off."
Woman With Short-Lasting, Strictly Unilateral HeadachesOctober 1st 2007
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.
Two Women With Severe Headaches: Different Symptoms, Similar ApproachesMay 1st 2007
The headaches vary in severity, but she usually has severeheadaches (8 on a 10-point visual analog scale[VAS]) once or twice a week; she describes the latter assevere throbbing or pounding pain on the top of thehead but also involving the occipital and frontalareas and occasionally one or the other temple.
Woman With Daily Headaches That Have Become Refractory to TriptansJanuary 1st 2007
A 30-year-old woman complains that her headaches no longer respond to triptans; instead, they have increased in frequencyand severity. The pain interferes with her ability to work part-time and to take care of her 16-month-old daughter.
Boy With Severe Weekly Headaches Associated With GI UpsetJanuary 1st 2007
A 12-year-old boy complains of severe weekly headaches that last 2 to 3 hours. The pain involves both sides ofthe head and the frontal and occipital areas. Occasionally during a headache, the patient complains of some abdominaldiscomfort and pain. He becomes passive and irritable during the headache; he does not want to be aroundpeople, play, or even watch TV. The patient’s parents note that a few hours before a headache, he becomes somewhatrestless and agitated. The headaches started about 1 year earlier, and the headache pattern (frequency, duration,location of pain, and associated symptoms) has not changed since that time. The patient’s mother and maternalgrandmother suffer from migraine.
A 30-year-old woman complains that her headaches no longer respond to triptans; instead, they have increased in frequencyand severity. The pain interferes with her ability to work part-time and to take care of her 16-month-old daughter.About 12 years earlier, the patient started having migraine headaches. She had no significant medical history, norwas there any obvious precipitating event. Typically, she had 1 or 2 debilitating headaches a month. These were accompaniedby photophobia, nausea, and vomiting-but not by auras. Oral triptans usually relieved the pain and associatedsymptoms within 1 hour.
Unmasking the Cause of an "Alarm Clock" HeadacheDecember 31st 2006
Primary care doctor: Because of the patient’s age and theabsence of a headache history, I first considered such secondarycauses as tumor and temporal arteritis. However,MRI of the brain and erythrocyte sedimentation rate werenormal. I now suspect a sleep-related headache becausethe attacks occur only at night and awaken the patientfrom a sound sleep. How can I determine which type ofsleep-related headache is involved?
Woman With Dull Daily Headaches and Episodic “Knockout” AttacksDecember 31st 2006
A 40-year-old woman reports increasingly frequent and severe headaches during the past few months. She has had boutsof severe headaches since college, and episodic migraine was diagnosed a decade ago. She uses over-the-counter products(ibuprofen, ketoprofen, or aspirin) at the onset of an attack; if these fail to relieve symptoms, she takes hydrocodone/acetaminophen. During her worst attacks, she is typically forced to halt her activities, is unable to eat or drink, and mayvomit. For unresponsive or persistent (more than 24-hour) attacks, her husband drives her to the urgent care centerfor intravenous hydration, intramuscular promethazine, and additional doses of hydrocodone/acetaminophen. Accordingto the patient, a visit to the urgent care center “completely ruins our day.”
Woman With Worsening Headaches and Neurologic SymptomsOctober 1st 2006
A 37-year-old woman complains of frequent, severe headaches. She describes the pain as a pressure-like feeling that is usually located at the top of her head and occasionally spreads to one of her temples; she rates its intensity as 9 on a 10-point visual analog scale. The pain becomes throbbing when she tries to engage in any kind of physical activity.
Woman With Frequent Severe HeadachesSeptember 1st 2006
The patient is a 47-year-old white woman with frequent, intensely painful unilateral or bilateral headaches that occur behind her left eye or temporal area. These headaches cause throbbing pain that lasts about 40 to 50 minutes: the patient rates the pain severity as a 7 or 8 on a 10-point visual analog scale.
Coping With Postherpetic NeuralgiaApril 15th 2006
A 79-year-old woman with a 37-year history of type 2 diabetes mellitus complains of head pain that began more thana month ago and is localized to the left frontotemporal region. She characterizes the pain as constant and burning, with minimalfluctuations in intensity. The pain does not increase with any particular activity but is quite disabling; it has causedemotional lability and insomnia. She denies nausea, visual disturbances, weakness of the extremities, dizziness, or tinnitus.Her appetite is depressed; she has experienced some weight loss.
Severe Migraine: Options for Acute Therapy in the Emergency DepartmentMarch 2nd 2006
A 36-year-old man with a 15-year history of episodic migraine presents to the emergency department (ED) at 5 AM witha right-sided throbbing headache of 4 hours' duration. The headache awakened him, which is typical of his more severemigraine attacks. Unfortunately, the patient forgot to refill his prescription for pain medication and did not "catch" thisheadache in time. He took an over-the-counter combination of aspirin and caffeine, which seemed to help for about 60minutes, but the headache has returned full force. He has vomited twice-another characteristic typical of his migraineattacks
Young Woman With Headache Several Days After Lumbar PunctureOctober 1st 2005
A 24-year-old woman complains of a severe, throbbing headache that is present when she is upright and is relieved when she lies down. When she is upright, she also experiences dizziness, blurred vision, light sensitivity, nausea, and occasional diplopia.
Man With Incapacitating Daily HeadachesApril 2nd 2004
A 39-year-old man complains of severe daily headaches that he describes as throbbing and "burning," with a sensationof pressure. He rates the severity of his pain as 8 to 10 on a 10-point visual analog scale (VAS) in which 10 isthe most severe. The mean duration of the headaches is 12 hours, and the mean frequency is 5 days per week. Betweenthe episodes of severe headache, he has constant "minor" headaches that are not as severe (mean severity, 3 to 5 on a10-point VAS). Within the past 5 months, he has never been totally free of headache.
Man With Multiple Short-Lasting, Unilateral Daily HeadachesSeptember 1st 2003
The patient is a 56-year-old man who presents with daily headaches that occurbehind the right eye, right temple, and occasionally on the right side of theforehead. He has never experienced this type of headache on the left side. Hedescribes the pain as “stabbing,” “throbbing,” and occasionally “burning.”He rates the intensity of the pain a 7 on a 10-point visual analog scale onwhich 10 is the most severe.
When Are OTC Analgesics Appropriate for Acute Migraine?February 1st 2003
A 34-year-old woman complains of headaches that interfere with work. Her first headache episode, approximately 6 yearsearlier, was relatively mild. Initially, she experienced attacks only once every 3 to 4 months and managed them effectivelywith over-the-counter (OTC) agents. However, in the last 6 months the attacks have become more frequent-they occur atleast twice a month-and are so severe that she misses work.
Chronic Subdural Hematoma: "Symptoms Are Indefinite, and the Diagnosis Cannot Be Made With Certainty"November 1st 2002
A 69-year-old retired accountant presents with a 2-month history of daily headaches. The pain is moderate, constant,global, pressure-like, and occasionally pulsating; it is sometimes exacerbated when the patient lies down. He denies nauseaor vomiting, ocular symptoms, weakness, or sensitivity to light. His wife reports that years ago he experienced throbbingheadaches regularly.
An Approach to the Patient With Abdominal MigraineSeptember 1st 2002
A bright, active 10-year-old boy has been experiencing recurrent bouts ofabdominal pain with nausea and occasional vomiting for 3 years. Although hehas had 1 or 2 attacks at school, the pain usually occurs at home-frequentlyon weekends. His mother has been unable to correlate these episodes with particularfoods or activities. She notes that her son has experienced motion sicknessduring long auto trips and during a family holiday in the mountains ofColorado.