Eric M. Pearlman, MD, PhD Assistant Professor of Pediatrics Mercer University School of Medicine Savannah, GA. Woman with Frequent Headaches
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1 Eric M. Pearlman, MD, PhD Assistant Professor of Pediatrics Mercer University School of Medicine Savannah, GA Woman with Frequent Headaches
2 Learning Objectives At the conclusion of this case, participants should be able to: Recognize chronic migraine and distinguish it from other headache disorders and Be familiar with evidence-based treatment choices for management of patients with frequent headache and/or migraine.
3 Medical History JW is a 47-year-old woman Headache occurring virtually daily History of migraine without aura since age 16 y Moderate-to-severe intensity Associated with photophobia, phonophobia, and nausea Disability: movement made pain worse or exacerbates the throbbing Used NSAIDs and ASA for 37 yo started triptan
4 Complaints at Clinical Presentation 6 months ago, she noticed an increase in migraine frequency 3/wk (about 18 headache days per month) Less severe in intensity Associated with photophobia and nausea Symptoms often worsen with movement or activity Difficulty falling asleep and staying asleep Feelings of sleep deprivation
5 Medication History Medical history Migraine headache- since teen years. Previously tried topiramate and propranolol as preventive therapies without success Generalized anxiety History of depression Peptic ulcer disease Hypercholesterolemia Current Medications TriptanPRN Combination analgesic (AAC) for rescue PRN (< 5/mo) Citalopram 40 mg po qd for headache prevention, anxiety and potential depression Pantoprazole 40 mg po qd for peptic ulcer disease Simvastatin 20 mg po qd for hypercholesterolemia
6 Family/Social History Family history Father: hypertension, hypercholesterolemia Mother: noninsulin-dependent diabetes Sister: episodic migraine without aura Social history Married, 3 children (2 home, 1 college). Accountant at large firm
7 Review of Systems Complains of fatigue but denies any recent infections or illness Weight and appetite have been stable No recent or remote history of head trauma No SOB, dyspnea, dizziness, or syncope No chest pain No abdominal pain, vomiting, diarrhea, or constipation Denies BRBPR or melena Denies hematuria Menstrual periods are regular Denies arthralgias or myalgias Denies focal motor weakness or loss of sensation Mood: frustrated about the headaches ; can t sleep Sexually active but frequent headaches impacted sex drive
8 Question 1 Which of the following would be useful in the further evaluation of this patient? Additional history about medication use MRI CT CBC and laboratory tests Additional history regarding sleep, depression and anxiety
9 Question 1 Which of the following would be useful in the further evaluation of this patient? Additional history about medication use MRI CT CBC and laboratory tests Additional history regarding sleep, depression and anxiety
10 When might MRI and CT be warranted? SNOOP SYSTEMIC SYMPTOMS (fever, weight loss) or SECONDARY RISK FACTORS (HIV, systemic cancer) NEUROLOGIC SYMPTOMS or abnormal signs (confusion, impaired alertness or consciousness) ONSET: sudden, abrupt, or split-second OLDER: new onset and progressive headache, especially in middle age >50 yr (giant cell arteritis) PEVIOUS HEADACHE HISTORY: first headache or different (change in attack frequency, severity, or clinical features)
11 Additional Medication History Age 30: 4-week course of propranolol 40 mg Followed by 4 week course of 80 mg Discontinued Age 43: 1 week topiramate 50 mg/d Escalated to 100 mg/d Discontinued after 2 nd week due to paresthesias Current medications Citalopram 3 months, no change in HA frequency AAC/NSAIDs 3-5 times per month No alcohol or tobacco use; morning caffeine use No exacerbation of HA when not drinking caffeine
12 Additional Psychosocial History Additional history regarding sleep and depression Difficulty winding down at night to go to sleep 30 minutes to 3 hours to fall asleep Awakens around 3:00 am and unable to go back to sleep No snoring or other symptoms of obstructive sleep apnea No symptoms of restless leg syndrome No symptoms of daytime somnolence or narcolepsy If she had symptoms characteristic of a primary sleep disorder, a polysomnogram and/or multiple sleep latency test may be appropriate
13 Question 2: What is the primary diagnosis for this patient? Episodic migraine Chronic migraine Chronic tension-type headache Medication overuse headache Caffeine withdrawal headache
14 Question 2: What is the Primary Diagnosis for JW? Episodic migraine Chronic migraine Chronic tension-type headache Medication overuse headache Caffeine withdrawal headache
15 Clinical Course I Provided a diagnosis of chronic migraine without aura Instructed to identify migraine attacks vs other HA types Advised on life-style modifications: Regular exercise Routine meals Regular sleep hygiene Stress management Counseled to monitor/restrict daily use of caffeine and other analgesic/rescue medications Reviewed risk of developing medication-overuse headache Restrict to < 2 doses per week Switch to NSAID with no caffeine (eg. naproxen sodium)
16 Question 3: What migraine preventive medication might be appropriate in this patient? Paroxetine Verapamil Atenolol Amitriptyline
17 Question 3: What migraine preventive medication might be appropriate in this patient? Paroxetine Verapamil Atenolol Amitriptyline For migraine, effective doses of amitriptyline range from mg given once at night. To minimize side effects, the patient is started on 10 mg and the dose increased in 10-mg increments every 3-4 days until reaching the target dose (eg. 50 mg). Common side effects include somnolence, weight gain, and orthostatic hypotension.
18 Question 4: If JW headaches gets worse in the first 3 weeks, what should be done? Tell her to increase her use of analgesics and triptans Obtain an MRI of the brain Change preventive medications Focus on good headache hygiene habits and provide reassurance Do additional SNOOP and repeat exam
19 Question 4: If JW headaches gets worse, what should be done? Tell her to increase her use of analgesics and triptans Obtain an MRI of the brain Change preventive medications Focus on good headache hygiene habits, provide reassurance, and manage expectations Do additional SNOOP and repeat exam
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MEDICATION GUIDE. TOPAMAX (TOE-PA-MAX) (topiramate) Tablets and Sprinkle Capsules
MEDICATION GUIDE TOPAMAX (TOE-PA-MAX) (topiramate) Tablets and Sprinkle Capsules Read this Medication Guide before you start taking TOPAMAX and each time you get a refill. There may be new information.
PATIENT INFORMATION SHEET. Last Name: First Name: MI: Home Address: Apt# City: State: Zip Code: Home Phone #: Cell Phone #:
PATIENT INFORMATION SHEET PATIENT Last Name: First Name: MI: Gender: M F Date of Birth: / / SS# Home Address: Apt# City: State: Zip Code: Home Phone #: Cell Phone #: Employer Name: Work Phone #: Email
Southwest General Surgical Associates General & Vascular Surgery 8230 Walnut Hill Lane Suite 408 Dallas, TX 75231 Phone-214)369-5432 Fax-214)369-5591
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Denver Spine Surgeons David Wong, MD, Sanjay Jatana, MD, Gary Ghiselli, MD
Cervical and Lumbar Spine Health History Name: Today s Date: Referring Provider: How did you find us: (Please circle) Primary care physician, Google search, Facebook, Friend or Family member, Website (JatanaSpine