George Nissan, DO

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 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.