1 / 34

Patient History

Migraines Mark Green, MD Clinical Professor Department of Neurology Columbia University New York, NY. Patient History. Patient is a 36-year old woman with a 10-year history of recurring headaches Average 2 headaches per month

ardara
Download Presentation

Patient History

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. MigrainesMark Green, MDClinical ProfessorDepartment of NeurologyColumbia University New York, NY

  2. Patient History • Patient is a 36-year old woman with a 10-year history of recurring headaches • Average 2 headaches per month • Headaches are left-sided, hemicranial, and associated with nausea and vomiting • Attacks last 2 days, afterwards she is well

  3. Patient History • Patient is a 38-year old woman with a long history of unilateral throbbing headaches associated with nausea and vomiting • Headaches last 2 days and are particularly likely to occur while menstruating • Over past 6 months, headaches have increased; still unilateral but continuous • Taking 50 Excedrin Migraine tablets each week for headache and getting only temporary relief

  4. Drug Overuse in Headache Patients Regular use of • Analgesics • Vasoconstrictors • Decongestants • Caffeine • Triptans, NSAIDs (rare)

  5. Why is a migraine disabling? • Pain • Nausea, vomiting • Photophobia and phonophobia • Encephalopathy

  6. Common Comorbidities of Migraine • Cardiovascular • Hypertension or hypotension • Raynaud’s disease • Mitral valve prolapse • Angina / myocardial infarction • Stroke • Respiratory • Asthma • Allergies

  7. Common Comorbidities of Migraine • Gastrointestinal • Irritable bowel disease • Neurologic • Epilepsy • Psychiatric • Depression • Bipolar disorder • Panic disorder • Anxiety disorder

  8. Problems with Narcotic Analgesics • Sedating • Increases nausea and vomiting • Vasodilator • Rebound headaches • Drug-seeking behavior

  9. Dopamine Antagonists • Chlorpromazine • Metoclopramide • Prochlorperazine • Droperidol

  10. Problems with Dopamine Antagonists • Sedating • Orthostatic hypotension • Extrapyramidal effects

  11. NSAIDs • Ketorolac (parenteral) • Indomethacin (suppositories)

  12. Triptans in the ER • Injectable sumatriptan most likely to work in a prolonged migraine • Comorbidities • Medications taken before ER

  13. Dihydroergotamine • Intravenous or intramuscular • Pretreat with an antiemetic • Cannot mix with triptans/other ergots

  14. Corticosteroids • Reduce rate of headache recurrence • Little immediate relief

  15. Depacon • 1 gram IV in 50 cc NS by rapid infusion over 5 minutes • Compatible with use of triptans/ergots same day • No sedation • Improvement in associated migraine symptoms • Can begin prophylaxis immediately if desired

  16. Patient History • Patient is a 37-year old woman who had abrupt onset of a severe occipital headache with mild nausea • Had transient diplopia, which resolved before she arrived at the hospital • Headache remained constant without any photophobia but with moderate nausea • Her neurological examination was normal and her headache and nausea responded well to sumatriptan and she was discharged

  17. Patient History A 45-year old male presented to the emergency room in the evening. He had a long history of migraine without aura, which was treated with rizatriptan. This treatment has been generally successful in the past, but he did not respond on this occasion. He had taken it at 3am when he was awakened with a unilateral throbbing headache accompanied by nausea and vomiting. The rest of the evening and throughout the morning he continued to vomit frequently and did not appear to improve taking ibuprofen every 4 hours.

  18. When would you do a CT scan on this man? • If his neurological examination is normal. • If he does not respond to another dose of rizatriptan. • If he does not have a pre-existing history of migraines.

  19. What would be your next treatment? • Another dose of rizatriptan, in the MLT formation. • Injectable sumatriptan. • Intravenous prochlorperazine. • Intravenous divalproex.

  20. Patient History • Patient is a 37-year old woman who had abrupt onset of a severe occipital headache with mild nausea • Had transient diplopia, which resolved before she arrived at the hospital • Headache remained constant without any photophobia but with moderate nausea • Her neurological examination was normal and her headache and nausea responded well to sumatriptan and she was discharged

  21. The response to medication is not diagnostic of the problem.

More Related