RESPONSE DISCUSSION

Post an explanation of the differential diagnosis for the patient in the case study you selected. Explain which is the most likely diagnosis for the patient and why. Then, based on the appropriate clinical guidelines, explain a treatment and management plan for the patient, including proper dosages for any recommended treatments. Finally, explain strategies for educating patients on the disorder.

Case Study # 3-

A 32-year-old Asian American female is in the clinic for a history of recurrent headaches for the past year, occurring monthly, lasting up to 12–18 hours. The headaches are sometimes associated with photophobia, nausea, and vomiting. She takes either acetaminophen or ibuprofen for relief that is not always successful. She uses Ortho Tricyclin for birth control. Her physical exam is within normal limits.

Headaches, specifically migraines, are much more common in women due to hormonal fluctuations associated with pregnancy, menopause, and use of oral contraceptive pills that can impact migraine frequency and intensity (Kalidas, 2017). While this patient appears to be having a migraine, the differential diagnoses will be briefly discussed.

Differential Diagnoses

Episodic tension-type headaches can be described as infrequent and bilateral with a hatband distribution that may last minutes to days (Jay & Barkin, 2017). While it can be associated with photophobia or phonophobia, it is not associated with nausea (Jay & Barkin, 2017). The absence of nausea is one factor that helps to differentiate this type of headache from a migraine.

Medication overuse headache is another differential diagnosis for this patient. She reports she has had headaches monthly for a year and has been taking acetaminophen and ibuprofen which are not always successful. Having headaches for this long and taking medications that do not always provide relief places her at risk for potentially abusing these medications in an attempt to treat her pain. Criteria for diagnosis include having headaches that occur 15 days or more a month with regular overuse of one or more drugs taken for acute or symptomatic treatment for greater than 3 months (Jay & Barkin, 2017). It does not sound like she is having 15 days or more a month of headaches and it is unclear of her medication use, only that she doesn't get much relief from ibuprofen and acetaminophen.

Most Likely Diagnosis

The most likely diagnosis for this patient is a migraine, specifically a menstrual migraine. Menstrual migraines fall into 2 categories, either a pure menstrual migraine or a menstrual related migraine (Kalidas, 2017). Without knowing more information, it is difficult to determine which type this patient may be experiencing. It is important to ask her how many she has a month, what time of the month they occur, and whether she experiences an associated aura or not. Assuming she is having it once a month, it is occurring anywhere from 2 days prior to menses to 3 days after menses, and she has no aura, she is likely having a menstrual migraine (Kalidas, 2017). These migraines are hypothesized to occur due to an abrupt drop in estrogen that occurs with menses monthly (Kalidas, 2017).

Treatment and Management Plan

In developing a treatment plan for menstrual migraines, it is important to note that these types of migraines are typically associated with higher severity and disability and more resistant to treatment (Kalidas, 2017). Medications that may be used in treatment and management include nonsteroidal anti-inflammatory drugs (NSAIDSs) and triptans (Kalidas, 2017). Medications that can help manage migraine-related pain and this patient’s photophobia, nausea, and vomiting include combination analgesics and antiemetics (Kalidas, 2017). This patient has shared that she has tried ibuprofen and acetaminophen in the past without much success. An important consideration in the selection of medications for a patient with menstrual migraines is the decision on whether they will require abortive, prophylactic therapy, or a combination. It is recommended that patients with menstrual migraines try using prophylactic triptans for 2 days prior to the onset of menses and continue use for 5 to 7 days (Hayon, Carlson, McMillen, & Schrager, 2016).

Another very important part of managing this patient’s migraines is addressing her current birth control, ortho tricyclin contraceptive pills. This is another important reason for inquiring as to whether this patient has an aura with her migraine headaches because combined oral contraceptives are contraindicated in women who have migraine with aura due to an increased risk of stroke (Calhoun & Batur, 2017). Current guidelines, however, do not suggest restriction of oral contraceptives in the setting of migraine without aura unless the patient has other risk factors present for stroke (Calhoun & Batur, 2017). It is interesting as the American College of Obstetrics and Gynecology discuss extended-cycle or continuous hormonal contraceptives may provide relief of migraines by eliminating drops in estrogen levels that often precipitate them (Calhoun & Batur, 2017). It is still recommended safe practice to consider nonestrogen methods of contraception in all women who have migraine with focal neurologic signs, who smoke, and all women age 35 and older (Calhoun & Batur, 2017). Given that this patient is assumed to not smoke, is 32 years of age, and is not experiencing focal neurological deficits, I would continue her on her oral contraceptives for now. Due to being on this type of contraception, she would be a good candidate for abortive triptan therapy as she can predict when her menses is coming and prophylactically take a triptan 2-3 days before onset and continue for another 5 to 7 days (Hayon et al., 2016).

For specific treatment for this patient, I would recommend that she begin treatment 2 days prior to her menses with 550 mg of naproxen BID taken with naratriptan 1 mg orally BID and continue to take for at least 3 days after menses (Kalidas et al., 2016). If her nausea continues despite this combination, I would prescribe her an antiemetic but for now I would try her on these two medications in combination as they have had great success in controlling migraines and associated symptoms in addition to being useful in decreasing the duration, frequency, intensity, and disability associated with these types of migraines (Kalidas et al., 2016).

Education Strategies

It is important when evaluating headache disorders to know when neuroimaging is warranted. Examples of when it would be appropriate to order neuroimaging studies include a significant change in attack frequency or severity, new clinical features that may include vision, speech, weakness, numbness, or tingling (Kalidas, 2017). Acute changes that include impaired alertness, confusion, or a quickly escalating headache also warrant imaging (Kalidas, 2017). In the case of this patient, she has had consistent headaches over a year and imaging studies are not warranted at this point. Education would include how to take the above medications and the importance of taking them prior to menses and continuing for 3 days afterward. Keeping a journal of when headaches occur including information about severity can help identify possible triggers to avoid and will be included in education. It is always important for her to keep a regular sleep schedule and to stay hydrated.

Resources

Calhoun, A. H., & Batur, P. (2017). Combined hormonal contraceptives and migraine: An update on the evidence. Cleveland Clinic Journal of Medicine, 84(8), 631–638. https://doi-org.ezp.waldenulibrary.org/10.3949/ccjm.84a.16033

Hayon, R., Carlson, J., McMillen, J., & Schrager, S. (2016). Menstrual migraines: Which options and when? The Journal of Family Practice, 65(10), 686–697. Retrieved from https://search-ebscohost-com.ezp.waldenulibrary.org/login.aspx?direct=true&db=mnh&AN=27846327&site=ehost-live&scope=site

Jay, G. W., & Barkin, R. L. (2017). Primary headache disorders- Part 2: Tension-type headache and medication overuse headache. Disease-A-Month: DM, 63(12), 342–367. https://doi-org.ezp.waldenulibrary.org/10.1016/j.disamonth.2017.05.001

Kalidas, K. (2017). Migraines in Women: Fluctuating hormones play a role in migraines, making it important to consider hormonal milestones and factors when formulating a treatment plan. Contemporary OB/GYN, 62(8), 12–16. Retrieved from https://search-ebscohost-com.ezp.waldenulibrary.org/login.aspx?direct=true&db=rzh&AN=124667382&site=ehost-live&scope=site

Tepper, N. K., Whiteman, M. K., Zapata, L. B., Marchbanks, P. A., & Curtis, K. M. (2016). Safety of hormonal contraceptives among women with migraine: A systematic review. Contraception, 94(6), 630–640. https://doi-org.ezp.waldenulibrary.org/10.1016/j.contraception.2016.04.016