Migraine

A 36-year-old man who had collapsedand sustained a bruised right shoulderwas brought to the emergency departmentwith acute emesis, cephalgia,blurred vision, aphasia, and righthemiparesis. He was confused but ableto follow simple commands.

A neurologic deficit caused by a transient ischemic attack should last less than 24 hours. This woman presented with signs of paresis that had persisted for 36 hours, thus ruling out transient ischemic attack.

Most primary care practitioners approach the patient who complains of dizziness with some trepidation. This is chiefly because the differential diagnosis involves multiple organ systems and a wide variety of disorders. In this article, I offer a rational, straightforward, and cost-effective approach that uses only minimal, selective diagnostic testing.

A 71-year-old man presented with a 6-week history of decreased vision in his right eye. The patient, who had hypertension and migraine headaches, had successfully recovered from a stroke that occurred 1 year earlier. His medications included aspirin, 81 mg/d, clopidogrel, atenolol, and furosemide. He also took gabapentin, 300 mg hs, for his migraine headaches. He had a remote history of cigarette smoking.

What are the current recommendations for the use of corticosteroids in the treatment of migraine? Is this a therapy primary care clinicians might consider?

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.