What is your primary diagnosis now? What medication therapy would you initiate?
The patient is experiencing headaches that are accompanied by symptoms’ of nausea and being sick. This type of head fits the description of migraine, which is a complex condition with various symptoms, including painful headaches, sensitivity to light, feeling sick, and vomiting. Even though nausea is common among migraine patients, vomiting is less frequent. Mostly, the patient would experience nausea with most of the headaches, vomiting in few of the headaches, and none of these symptoms with some of the headaches. Most women have been found to have their first migraines at puberty on the onset of menstruation, which has been the case with the patient. Unilateral pain, exhaustion, stiff neck, craving for sweets, and yawning are also common migraine symptoms. In addition, pulsating or throbbing pain could indicate the presence of migraines. The recurrent headache fits migraine symptoms from the patient’s symptoms (Monteith & Goadsby, 2011).
Treatment of the migraine would involve considering medication that prevents migraine attacks instead of treating each individual attack. In addition, the treatment should identify the possible trigger factors and relieve the symptoms of a migraine attack. Since naproxen sodium, acetaminophen, butalbital and caffeine have not been effective, the patient could use triptan, an option for patients who have not responded to analgesics. Estrogen supplements could be used to increase the level of estrogen before and during menstruation. This would be effective fall of estrogen before menstruation is thought to be a trigger of migraines. The patient could also take a contraceptive pill with less progesterone. Migraine prophylaxis could also be used because the attacks are occurring 2-3 times a month. If prophylaxis is used, then medications like propranolol or amitriptyline can be considered for the treatment. The treatment might not completely prevent all the migraines, but will make the migraines less severe and less frequent (Lainez, Garcia-Casado, & Gascon, 2013).
She responds very well to the tryptan therapy you initiated. What frequency of follow-up is warranted, and what non-pharmacologic options might help decrease the severity and frequency of her headaches?
Since the current patient’s headaches meet the International Headache Society criteria for migraine without aura, she cannot use the contraceptive path especially if she is older than 35 to relieve the pain. Triptan is therefore a good choice for treating the migraines. Most of the patients using triptan therapy experience pain relief just 2 hours after taking the medication. A second dose is recommended if the headache recurs. Failure with one triptan medication does not mean another medication from triptan family will not be effective. For patients with migraines associate with nausea or vomiting, then oral administration of triptan is discouraged. Triptan could be taken subcutaneously or intra-nasally and its action is as fast as 15 minutes. The patient should not however take triptan more often than three days per week and if they are doing so, triptan therapy should be stopped and preventive treatment be used instead (Silberstein, & Patel, 2014).
Other non-pharmacologic options that might help in decreasing the severity and frequency of the patient’s headaches include lifestyle changes. Stress is a common trigger for headaches and migraine especially the nauseating migraines and so worrying less and reducing stress could be effective in reducing the frequency and severity of migraine attacks. The patients could also avoid alcohol and cigarettes as these could trigger migraines. Migraines improve with rest, sleep, quiet and drinking water could help reduce the frequency and severity of migraine symptoms. Acupuncture could also be an effective way of minimizing migraines and its related symptoms.