Migraine Headache Case Study

Chief Complaint

Migraine headaches.

History

Patient is a 19-year-old right-handed white male who presents with his mother for evaluation of frequent headaches. He did not have headaches prior to two grade 1 concussions while playing football in 2012. At that time, he had a normal MRI. He has been having headaches since. He did see Kent Logan, MD in 2012, at which point he was describing weekly headaches with photophobia, phonophobia, and nausea. At that time, according to Dr. Logan's notes, there was no aura with his headaches. He noted that trying one of his mother's Imitrex helped with the headache, so he was given a prescription for 50 mg. He was also diagnosed as having a whiplash injury, at that time. He did undergo physical therapy for his neck. He also was complaining of some short-term memory problems at that time, but neuropsychology testing was negative. He has not followed up with Dr. Logan since then. More recently, his headaches have been increasing in frequency. They are located in the left retrobulbar and super orbital area, but then will spread throughout the left side of the head and then bilaterally. The pain is steady when it is milder, but throbbing when it is worse, and it is worsened with exertion. There is photophobia, phonophobia, osmophobia, nausea. They can last one to two hours. Most often, he does have

a scintillating scotoma with them. Precipitants include odors, sun, possibly bouncing around in the tractor, prolonged reading or computer work and having to take tests. He was given 25 mg of Imitrex by his PCP to hold him over. Over the past several months, he has been using Aleve or Motrin very frequently. His frequency is two to three headaches a week and it has been like this for about four months. Last year, he was having maybe two or three headaches a month. He also has a history of vasovagal syncope, not always temporally related to a headache. It occurs when he is upright, never when he seated or lying. There is no tonic or clonic motion. There is no tongue biting, bowel or bladder incontinence. He has no other symptoms that sound like nocturnal, generalized, or partial seizures. He has not had any cardiac work up or tilt table testing. He does have panic attacks that are related, and anxiety that are related to these episodes of vasovagal syncope. Also, his mother notes that when he starts to get a migraine or migraine aura, he becomes anxious about it. His anxiety regarding his syncope has led to a significant change in his day-to-day living in that currently he no longer flies alone to visit his father in Minnesota. The vasovagal syncope and anxiety are significantly affecting his quality of life.

Review of Systems
Syncope, neck pain, poor sleep.

Social History

He does not smoke. He does not drink alcohol. He is at Great Bay studying liberal arts.

Family History

Mother and maternal grandmother with migraines, breast cancer in the family, diabetes, SLE, fibromyalgia.

Past Medical History

He does have vasovagal syncope 15 to 20 times a year or more.

Panic attacks three to four times a week.

He did have Burkitt's lymphoma at three years old and underwent chemotherapy. He was told that he would have cardiac issues after that, but follow up EKGs have been normal.

Allergies

Cephalosporins, amoxicillin,

Augmentin.

Medications
Imitrex 25 mg, lorazepam 0.5 mg.

Examination
Constitutional
Weight 180 pounds. Height 5'10". Respirations 12. Pulse 69.

General
He is in no obvious distress.

Cardiovascular
Carotids reveal no bruits.

Mental status
He is oriented x3, alert, cooperative. Good short-term, long-term and intermediate memory. No aphasia. Normal fund of knowledge. Normal attention and concentration.

Cranial Nerves
The fundi were benign. Visual fields full to confrontation. Extraocular muscles intact. PERRLADC. Normal facial symmetry, sensation, and movement. Tongue and uvula were midline. Normal auditory acuity. Normal shoulder shrug.

Motor
Was 5/5. No fix or drift. Normal tone all four extremities.

Sensory
Was intact to primary modalities with no extinction on double simultaneous stimulation.

Cerebellar
Revealed good finger-to-nose, heel-to-shin and rapid alternating motion.

Gait
Normal. Negative Romberg.

DTRs
2+ throughout. Toes are downgoing.

Impression
This is an individual who does have migraine with aura, and they are frequent enough for prophylaxis. Currently, he may also be suffering from a component of medication overuse headache. He also has frequent vasovagal syncope, which is resulting in anxiety and panic attacks and significantly adversely affecting his quality of life. He also has some neck pain, which he thinks may be precipitating some of the migraines.

Plan
My plan right now is to start him on amitriptyline, titrating to 25 mg at night. This is for his migraine prophylaxis. It also may help with the cervicalgia and certainly will help to regulate his sleep. It may also have a mild anti-anxiety component to it. I am giving him Imitrex 50 mg to use p.r.n. He is going to keep a headache diary. I am going to do an EEG just to rule out any possible seizure-like activity, after which I will discuss with the mother and patient whether or not to set him up with a cardiologist for a full cardiac evaluation and possibly tilt table test, considering his Burkitt's lymphoma, and a being told as a child that he may have cardiac issues. I will see him in followup in one month.