Migraine

A 53-year-old woman, who has a remote history of acne, says that facial rednessappears each time she has a migraine. Her migraine medication, fiorinalwith codeine, ameliorates the headache, but the erythema lingers for days.

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?

Clinician: The patient’s symptom profile is confusing, especiallybecause his test results are normal. Are his amnesicepisodes related to his migraine?

Which of these scenarios is familiarto you? •A local pharmacist calls to say thatyour patient wants another refill for thecombination analgesic containing aspirin,caffeine, and butalbital that youprescribed last week. Pharmacy recordsindicate that this patient has received250 tablets of this medication inthe last 34 days.

A 60-year-old man has had anterior neck discomfort for the pastseveral weeks. He also has right-sided cephalalgia and occasional jaw discomfortwhile eating but no dysphagia or odynophagia. The cephalalgia, which hasbeen present for the past week, is moderately severe and is associated withblurred vision.

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.”

A 45-year-old man has a history of migraine that started shortly after puberty. The headaches became more frequent andsevere 3 years ago, when the patient was promoted from metal worker to shift boss.

IRVINE, Calif.-- Methamphetamine users may develop carotid artery dissections, leading to a severe stroke, an effect also seen in cocaine users, according to researchers here.

We describe a rare case in which chest pain and subcutaneous emphysema developed while the patient was undergoing routine dental extractions under local anesthesia and inhaled nitrous oxide. The patient was found to have extensive pneumomediastinum on a CT scan of the chest. The patient received supportive care and 24-hour high-flow oxygen (100%) and was discharged the next day without any residual symptoms. At a 10-day follow-up visit, neck and chest radiographs revealed no further subcutaneous emphysema.

A 49-year-old man presents with recurring facial pain of 6 months' duration. The pain initially occurred several times per week; it now occurs as often as several times per day. The paroxysmal pain is intense and incapacitating but abates within several minutes. It occurs in the right maxillary region and lower jaw and is sharp and lancinating. Hard chewing and teeth cleaning are the usual precipitating events. Between episodes, the patient is asymptomatic, without numbness or deficit in the affected region.

HYATTSVILLE, Md. -- Persistent pain is remarkably prevalent in America, according to a CDC report. Pain from lower backs, knees, and migraine stood out from the rest.

Although it has been evident since the early days of the HIV epidemic that a dementing illness often accompanies HIV infection and that the virus invades the nervous system soon after systemic infection, the clinical syndrome has evolved with the introduction of antiretroviral therapy.

PALERMO, Italy -- It may take 10 to 20 years, but as children and teenagers reach adulthood, migraine headaches often disappear, alter, or become less severe, researchers here reported.

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.

BOSTON -- When a diagnosis of irritable bowel syndrome comes to mind, consider migraine, fibromyalgia, and depression as well.

Hepatomegaly is detected during the routine physical examination of a healthy 40-year-old woman who is employed as a secretary. She has noticed some fullness in the right upper abdomen for many years, but it has not been accompanied by pain or GI symptoms.

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.

Hepatomegaly is detected during the routine physical examination of a healthy 40-year-old woman. She has noticed some fullness in the right upper abdomen for many years, but it has not been accompanied by pain or GI symptoms.

You have been treating a 28-year-old woman for migraine for the past 4 years. This morning, after reading the headlines about the potential risks of mixing triptans with triptans , she calls your office to ask whether she should stop taking her antidepressant.

ROCKVILLE, Md. -- Mixing common migraine drugs such as Imitrex (sumatriptan) with antidepressants like Prozac (fluoxetine) or Cymbalta (duloxetine) can trigger a life-threatening condition called serotonin-syndrome, the FDA has warned.

Pregnancy, childbirth, and the puerperium are the times when women are at greatest risk for stroke. Women in their childbearing years are at a greater risk for stroke than men of the same age.

LOS ANGELES ? Migraine related to menstruation may be exacerbated by hormonal birth control measures, with more use of analgesics and more recurrences, researchers said here.

LOS ANGELES - Sleeping well, plus behavioral modification techniques, may be a start toward relieving the chronic, daily headaches called transformed migraine, researchers said here.

LOS ANGELES ? Children with headaches are more likely to be overweight or obese, researchers said here.

LOS ANGELES - During the last three months of their tours of duty in Iraq, U.S. soldiers were prone to twice as many migraines as the general population, according to army researchers.

LOS ANGELES - Patients can sense a migraine coming on even before it strikes, and they are almost always on target, even if the diagnostic symptoms they use differ from clinicians' criteria, researchers said here.

LOS ANGELES - If all else fails individually, throw the kitchen sink at some patients with migraine, recommends an Ohio investigator.

LOS ANGELES, June 26 - An anti-seizure agent can reduce the frequency of chronic migraine events, according to a researchers here.

LOS ANGELES ? When applied during the aura phase of migraine, two pulses from an investigational transcranial magnetic stimulator reduced some symptoms in 69% of patients, according to a pilot study reported here.

A 15-year-old boy complains of moderate to severe headaches that occur daily and usually last all day; the pain typically worsens toward the end of the day. How will you help this patient?