This is ReachMD. Welcome to this special series, Rethinking Migraine, sponsored by Lilly. On this episode, Dr. Nada Hindiyeh, Clinical Assistant Professor of Neurology & Neurological Sciences at Stanford School of Medicine, reviews a case study of Recurrent, Episodic Migraine.
So I’d like to start off by discussing a patient case, and with this the steps, we take in diagnosis, how to talk to patients about their diagnosis and how to decide on treatment options. So this is a 35-year-old woman who presented to the headache clinic for evaluation of worsening headaches. She reports having headaches since the age of 12, often occurring once every 2 to 3 months and typically lasting about a day and usually relieved by ibuprofen or sleep. Over the last 6 months, however, she’s noticed an increase in frequency to once monthly, an increase in duration where headaches are lasting 1 to 5 days, and an increase in severity. So she describes the headaches as throbbing at times and pressure-like at times, often starting in the left temporal area but usually radiating globally all over her head. She reports associated sensitivity to light and sound as well as nausea and vomiting. She finds herself unable to keep food or pills down due to the vomiting and finds ibuprofen to no longer be effective. She works as a lawyer and has been missing several days of work a month because of this. So she reports stress, lack of sleep and skipped meals to be triggers, and with a recent deadline approaching at work, all of these factors have been intensified. She also reports no real time for exercise in the last several months. She has no significant past medical history but does report her mother has similar headaches, and her physical and neurological exam are normal. So based on her clinical presentation, she meets the diagnostic criteria for episodic migraine without aura. It’s not uncommon to see a patient like her who has had migraines since childhood but no formal diagnosis of migraine. Migraine is a clinical diagnosis based on criteria currently set forth by the International Classification of Headache Disorders, or the ICHD. So since she’s never been diagnosed with migraine before, it’s important to educate her on what we know about migraine. So although the exact mechanisms are still under research, we do know that migraineurs have a genetic predisposition to a hyperexcitable brain that is provoked by internal or environmental triggers. Assessing treatment plan will go hand-in-hand with assessing her quality of life and migraine impact, so she would certainly benefit from an abortive medication, such as a triptan ; and given her nausea and vomiting, she may especially benefit from a route of administration such as a subcutaneous injection or a nasal spray. She may also benefit from the addition of an antiemetic. And then consideration of a preventive medication will depend on the patient’s preference and disability. Given this patient’s demanding job and decreased productivity at work, she preferred to add a prescription daily preventive medication on top of lifestyle modifications she would start implementing. It’s important to set patient expectations for reduction of severity and frequency of headaches. A good goal is to consider a 50% reduction in either as a success. For an abortive medication, you may want to give 3 to 4 tries before calling it a failure, and for preventive medications, you should consider at least 3 months at your goal dose before making any changes.
The preceding program was sponsored by Lilly. Content for this series is produced and controlled by ReachMD. This series is intended for healthcare professionals only. To revisit any part of this discussion and to access other episodes in this series, visit ReachMD.com/RethinkingMigraine. Thank you for listening. This is ReachMD. Be Part of the Knowledge.