A Young Patient Presenting With Headache

A 25-year-old woman presents to your clinic complaining of a bifrontal headache that started this morning. She describes the pain as throbbing and 8/10 in severity. She is complaining of photophobia and nausea. She has had similar headaches in the past, lasting a few hours to all day. She is unable to work during these headaches and prefers a dark, quiet room. The physical examination, including neurological exam, is unremarkable.

1. What is the most likely diagnosis?
2. What are the treatment options for this patient?
3.. What are the contraindications and reactions of triptans?

Answers:


What is the most likely diagnosis?

Answer: The patient most likely has migraine headaches.

Discussion: Migraine headaches may vary considerably in severity, time of day, and characteristics. Migraine headaches typically present in the first three decades of life. Attacks typically last
less than 1 day although they may occasionally last longer. Migraine headaches are typically moderate to severe in intensity, may occur at any time during the day, and occur with or without aura. Most migraine headaches are unilateral, preceded by aura, and accompanied by nausea and vomiting. They are more prevalent among women,
Migraine headaches were formerly classified as

• classic type (migraine with aura) and 
• common type (migraine without aura.) 

Typical auras develop over several minutes and last for less than 60 minutes. Auras may involve visual, language, sensory, or motor deficits. The visual auras are by far the most common and may appear as photopsias (flashes of light), (blind spots), or complex shapes that build or move across the visual field.

What are the treatment options for this patient?

Answer: Treatment options include:
1. Oral NSAIDs, including aspirin and combination analgesics containing caffeine, are a first-line choice for mild-to-moderate migraine attacks or severe attacks that have been NSAID responsive in the past.
2. The “migraine specific” treatments, commonly called the “triptans”(e.g., sumatriptan, zolmitriptan,)  are effective and relatively safe for the acute treatment of migraine headaches. Triptans are an appropriate initial treatment choice in patients with moderate-to-severe migraines
who have no contraindications to their use
3. Alternative vasoconstrictive agents, including DHE nasal spray (dihydroergotamine, ), can provide a safe and effective treatment of acute migraine attacks. DHE can be administered IV as well.

What are the contraindications and reactions of triptans?

Answer: Contraindications to the use of “triptans” include:

• Coronary artery disease.
• Uncontrolled hypertension.
• Use of an MAO inhibitor within the last 2 weeks.
• Use of an ergot preparation within the last 24 hours.

Caution should be used in patients with:

•  history of stroke, 
• known cardiac risk factors, and 
• impaired liver function.

Common reactions to triptans include :

• jaw tightness, 
• flushing, 
• anxiety,
• dizziness, and 
• sweating. 

These are uncomfortable but not dangerous. 

Serious reactions to triptans include: 

• coronary vasospasm,
• anaphylaxis, or 
• hypertensive crisis in patients with known CAD, 
• hypersensitivity to triptans, or 
• uncontrolled hypertension.