Migraine

Read the cases of 4 patients whose chief complaint is a 2-week history of neck pain, try your hand at making a quick diagnosis, then go to the next page to read the outcome.

The use of analgesics, specifically acetaminophen, has been proposed as one of the mechanisms for the rise in asthma prevalence in the last 30 to 40 years.1 Acetaminophen, approved by the FDA in 1951, is one of the most commonly used analgesics in adults and children. The association between asthma and acetaminophen has been reported in case reports, in the setting of oral challenge tests, and in larger clinical studies.2

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.

A physician who has chronic daily headaches is concerned that his alprazolam regimen (0.5 mg of alprazolam nightly) may be considered "excessive use."

These yellow asymptomatic lesions on the inner upper eyelids of a 36-year-old woman had persisted for 2 years. She had a history of type 2 diabetes mellitus, migraine, nicotine dependence, bipolar disorder, and obesity. Her medications included quinapril, insulin aspart injection, sumatriptan, ziprasidone, and temazepam.

Multiple sclerosis, the most common cause of disability among young adults, can take years to diagnose because symptoms may wax and wane over time, and patients may not initially seek evaluation.

ABSTRACT: The management of chronic daily headache is difficult and complex. Those affected have a sensitive nervous system, and their predisposition for a low tolerance to sensory stimuli appears to be inherited. Under appropriate conditions, the equilibrium or balance between bombardment from painful stimuli and the regulatory systems that inhibit those stimuli is disrupted, allowing painful stimuli to become manifest at a greater intensity than in the nonmigraineur. Successful management depends on close adherence to nonpharmacologic approaches and pharmacologic regimens that desensitize the system and restore equilibrium. Comorbid conditions must be identified and treated as well.

ABSTRACT: Syncope is often benign and self-limited; however, it may sometimes indicate a life-threatening condition. Advanced age, heart disease, and abnormal ECG findings are associated with potentially adverse outcomes. The initial evaluation, which consists of a careful history taking, physical examination, and ECG, often suffices to make the diagnosis. Neurally mediated disorders, the most common cause of syncope, are usually benign. Cardiac syncope, which usually requires admission and further assessment, may result from rhythm disturbances or from outflow obstruction attributable to structural or pathophysiologic mechanisms. Patients with cardiac syncope may be evaluated with echocardiography, Holter monitoring, stress testing, loop event recorders, or electrophysiologic studies. Other causes of syncope include orthostatic hypotension, use of certain medications, a primary neurologic disorder, and psychiatric disturbance. A significant number of patients have unexplained syncope.

On her third day of hospitalization for acute gallstone pancreatitis, a 49-year-old woman's platelet count fell to 113,000/L from 216,000/L the previous day.

A 47-year-old man presented to theemergency department with adrooping right eye. He also complainedof a constant right-sidedheadache of 1 week’s duration; thepain involved the temporal region.Another physician had diagnosednew-onset migraine and prescribedsumatriptan, which failed to alleviatethe pain. The patient had no weakness,vomiting, or double vision.Both his father and his son hadMarfan syndrome.

Until recently, celiac diseasewas considered a rare disorder.However, new evidencesuggests that about1% of Americans are affected.As serologic tests that detect autoantigensinvolved in celiac diseasebecome more widely used, morecases will likely be identified.1

The patient is a 47-year-old man who began to experiencefrequent headaches about 6 years before hepresented to a neurology clinic. The headaches rapidly progressedto become daily and almost constant. He describeda sensation of dull pressure in both temples that was presenton or within a few hours of awakening and that persistedfor the remainder of the day. He experienced a moreintense, disabling, throbbing pain in the same locationonce or twice a week, with photophobia and nausea, thatmight last 2 to 3 days. The patient took 2 to 6 over-thecounter(OTC) analgesic tablets each day-usually200 mg of ibuprofen. These would dull but not terminatethe pain.

ABSTRACT: When you approach a patient with a neurologic complaint, look for abnormal postures and bodily asymmetries. Careful history taking puts the patient's complaint in context and gives direction to the clinical investigation. Remember that a change in the character of an existing condition requires assessment as a new complaint. The mental status evaluation, at a minimum, considers the patient's level of alertness and orientation, including speech and comprehension. Distinguish among delirium, dementia, and psychosis, and avoid making a psychiatric diagnosis until organic causes have been excluded. Cranial nerves II to VIII are the most pertinent to the neurologic screening examination. The evaluation of cranial nerves II, III, IV, and VI is particularly important in patients with headache or visual disturbances and suspected intracranial lesions.

For 3 days, a 44-year-old man had several crops of tiny vesicles with raised erythematous bases on the right side of his neck and 2 elongated maculopapular lesions at the base of the neck. All of the lesions were within the C3 dermatome.

ABSTRACT: Consider prophylactic therapy for patients with frequent (5 or more per month), severe migraine attacks; commonly used agents include β-blockers, calcium channel blockers, antidepressants, and antiepileptic agents. Daily or alternate-day use of aspirin or an NSAID may also be helpful, and limited data suggest angiotensin II receptor blockers may provide effective migraine prophylaxis. For treatment of acute migraine attacks, triptans have emerged as the most effective agents. Controlled clinical trials have demonstrated that all the triptans have similar efficacy. The optimal strategy for an acute migraine attack is to initially administer a therapeutic agent at a dose sufficient to relieve symptoms. Intervention during the early, mild stages of an attack is more likely to alleviate pain than intervention after moderate to severe symptoms occur.

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.

The diagnosis and treatment of migraine as its own entity is a complicated and delicate balance between identification and management. The situation is more complex, however, when the patient with migraine presents with comorbid conditions (eg, mood, neurologic, or musculoskeletal pain disorders). These comorbid conditions have important clinical implications. In fact, the risk of these and other comorbid disorders is much higher for migraineurs than for persons without a history of migraine. Comorbid conditions can also complicate treatment in some patients because of the potential for drug interactions or exacerbation of one condition by therapy for the other. The onus is on the physician to consider migraine treatment regimens that include the potential to manage underlying comorbidities and, conversely, to consider treatment regimens when migraine itself may be secondary to other primary symptoms.

Treatment of fibromyalgia syndrome (FMS) is a challenge. However, most patients benefit from appropriate management. Essential to treatment are a physician's positive and empathetic attitude, continuous psychological support, patient education, patience, and a willingness to guide patients to do their part in management. Other important aspects involve addressing aggravating factors (eg, poor sleep, physical deconditioning, emotional distress) and employing various nonpharmacologic modalities (eg, regular physical exercise) and pharmacologic therapies. Drug treatment includes use of tricyclic medications alone or in combination with a selective serotonin reuptake inhibitor, and other centrally acting medications. Tender point injection is useful. It is important to individualize treatment. Management of FMS is both a science and an art.

ABSTRACT: The results of diagnostic tests do not correlate well with the presence and severity of pain. To avoid missing a serious underlying condition, look for "red flags," such as unexplained weight loss or acute bladder or bowel function changes in a patient with low back pain. Nonopioid medications can be more effective than opioids for certain types of pain (for example, antidepressants or anticonvulsants for neuropathic pain). When NSAIDs are indicated, cyclooxygenase-2 inhibitors are better choices for patients who are at risk for GI problems or who are receiving anticoagulants. However, if nonspecific NSAIDs are not contraindicated, consider using these far less expensive agents. The tricyclic antidepressants are more effective as analgesics than selective serotonin reuptake inhibitors. When opioids are indicated, start with less potent agents (tramadol, codeine, oxycodone, hydrocodone) and then progress to stronger ones (hydromorphone, fentanyl, methadone, morphine) if needed.

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.

Many patients who present to the emergency department(ED) with severe headache request a narcotic to relieve thepain.

You recently diagnosed migraine without aura in a patient who complains of headaches of moderate intensity. Is a migraine-specific prescription agent warranted?

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.

ABSTRACT: Systematic palpation can detect a trigger point; often, muscle spasms or a nodule will be present. Injection of the trigger point with a local anesthetic usually reduces pain promptly; the procedure can also effect long-term pain relief and increased range of motion. However, pain may recur and even worsen 1 to 3 days after an injection-either because additional injections are needed or because the trigger point was not completely injected. To maintain pain relief and improve strength and range of motion in the affected muscle following injection, recommend stretching exercises, physical or massage therapy, or rest. Trigger point injections can be associated with adverse effects (eg, temporary numbness, injection site irritation, and dizziness); complications include vasovagal syncope, skin infection, and compartment syndrome.

Calcium channel blockersare commonly prescribedto treat severalcardiovascular diseasesand may be helpful inother conditions, such as migraineand bipolar disorder.1 These agentsare associated with numerous clinicallysignificant drug interactions.1-3While some of these interactions,such as the effect of verapamil onserum digoxin concentrations, arewell-known, others are not widely recognized-yet warrant attention.

ABSTRACT: A thorough history and physical examination can establish the diagnosis of tension headache; further evaluation is generally unnecessary. In contrast, the workup of cervicogenic headache includes standard radiographs, 3-dimensional CT, MRI, and possibly electromyography; nerve blocks may also be used to confirm the diagnosis. Episodic tension headache can be treated effectively by trigger avoidance, behavioral modalities, and structured use of analgesics. Reserve opioids for patients with intractable headaches. Chronic tension headache is treated primarily by prophylactic measures, such as antidepressants and anticonvulsants, and behavioral and physical therapy. Treatment options for cervicogenic headache include analgesics; invasive procedures, such as trigger point injections, greater or lesser occipital nerve blocks, facet joint blocks, segmental nerve root blocks, and diskography; spinal manipulation; and behavioral approaches.

Anisocoria and partial eyelid ptosis were detected during the routine eye examination of a 66-year-old woman. These findings had not been present during an examination 2 years earlier. Because the patient had no symptoms, she could not recall when these signs began. Her general health was unremarkable; she had smoked 1 pack of cigarettes per day for 40 years

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.

A 37-year-old woman presents to the emergency departmentwith a diffuse, sharp, pounding headache,which started 2 hours earlier. She rates her discomfort as4 on a scale of 1 to 10. Neck muscle soreness is also present,but the pain does not radiate.

Three strategies have commonly been used for episodic migraine. In step care across attacks, the least expensive medications are tried for several episodes. If these fail, treatment is "stepped up" to specific agents.