case files neurology
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case files neurology


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unchanged in 24%, and worsens in 9%.
\u2756 Approximately 80% of people who get migraine headaches have a
family history of migraine, which implicates genetics in
susceptibility.
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\u2756 CASE 19
A 38-year-old white female has a history of headaches for at least 10 years.
The headaches now occur on a daily basis. They are of mild to moderate pain.
Usually, the pain is located in the temples and often radiates to the neck. The
patient also reports a different headache approximately three times per month
that is located over one eye and is often associated with nausea, vomiting, pho-
tophobia, and phonophobia. These headaches are often worse during her men-
strual cycle. The patient has a prior history of episodic migraine beginning in
her 20s. They initially occurred one to three times per year, but then pro-
gressed to as much as one to three times per week. The patient has tried many
over-the-counter (OTC) medications for her headaches and has used aceta-
minophen (Tylenol), aspirin, caffeine (Excedrin Migraine), ibuprofen, and
naproxen sodium (Aleve) with regularity. She is currently taking three aceta-
minophen (Tylenol) every 4 hours and still gets a headache. She notes that
when these headaches began, 2 acetaminophen (Tylenol) usually relieved the
headache, but now even the 18 acetaminophen (Tylenol) per day do not impact
her headache. Her general examination is within normal limits. Her neurolog-
ical examination does not reveal neck stiffness or muscle rigidity, abnormal
reflexes, weakness, or sensory changes.
\u25c6 What is the most likely diagnosis?
\u25c6 What is the most likely next diagnostic step?
\u25c6 What is the likely next step in therapy?
ANSWERS TO CASE 19: Chronic Headache
Summary: A 38-year-old white female has a 10-year history of daily
headaches, located in the temples and often radiating to the neck. The patient
also reports a different headache approximately three times per month, which
occurs over one eye and is often associated with nausea, vomiting, photopho-
bia, and phonophobia, exacerbated by menses. The patient has a prior history
of episodic migraine beginning in her 20s. Numerous OTC medications
including large acetaminophen doses are unhelpful. Her general examination
and neurologic examination are within normal limits.
\u25c6 Most Likely Diagnosis: Chronic daily headache with analgesic
rebound
\u25c6 Next Diagnostic Step: Neurologic examination
\u25c6 Next Step in Therapy: Taper acetaminophen (Tylenol) usage and
consider treatment with valproic acid or topiramate
Analysis
Objectives
1. Recognize chronic daily headache and be able to distinguish it from
migraine and other causes of headache.
2. Know what treatments are available for chronic daily headache includ-
ing both medications and nonmedication intervention.
3. Know what workup is necessary for patients with chronic daily
headache.
Considerations
When evaluating a patient for headache, the clinical history is of critical impor-
tance. The nature (type of pain and associated symptoms or triggers), severity,
and duration of the headache is important in determining what type of headache
it is and how to manage it. In this case, the patient has a prior history of
headaches. Her headaches are described as two types. She reports pain around
her temples and neck which occurs daily; these symptoms seem to be consis-
tent with a tension type of headache. She also has a frequently recurring
headache that occurs on one side and is associated with nausea and vomiting,
and sensitivity to light and sound, which is suggestive of a migraine headache.
The duration of these headaches is over many years. Although she has increased
frequency, the character of her headaches has not changed. Her examination is
normal. Therefore, her headaches are unlikely due to other etiologies, such as
162 CASE FILES: NEUROLOGY
tumor, infection, or trauma. Nevertheless, if the patient has not had imaging of
the head recently, an MRI or CT scan would be prudent. The history gives a
record of episodic migraines in the past, which have become chronic daily
headaches, transiently responsive to OTC analgesics. Once chronic daily
headache is confirmed and other etiologies such as infection and brain tumor
are ruled out, tapering of the acetaminophen and initiation of another medica-
tion such as the seizure medication valproic acid seems to be helpful in these
conditions.
APPROACH TO CHRONIC HEADACHE
Definitions
Vascular headache: A type of headache, including migraine, thought to
involve abnormal function of the brain\u2019s blood vessels or vascular system.
Migraine headache: The most common type of vascular headache is
migraine\u2014headaches that are usually characterized by severe pain on
one or both sides of the head, upset stomach, or disturbed vision.
Photophobia: Light sensitivity or an intolerance to light.
Phonophobia: Heightened sensitivity to sound.
Clinical Approach
The clinical entity chronic daily headache encompasses several headache syn-
dromes. These include chronic migraine headache, chronic tension type
headache, and new daily persistent headache. All of these entities can be com-
plicated by analgesic abuse.
Chronic Migraine Headache
Chronic migraine most often is seen in women who have had a history of
intermittent migraine, which usually began in their teens or twenties. The
headaches become much more frequent over the years, and these chronic
migraine headaches are usually not associated with the photophobia, phono-
phobia, or nausea. Even as these headaches become more chronic, many
patients still have intermittent episodic migraine, and these breakthrough, ran-
dom migraine headaches can be associated with nausea, vomiting, photopho-
bia, and phonophobia. A significant number of chronic migraine patients
suffer from underlying depression and anxiety. The entity of transformed
migraine speaks to this change from episodic migraine to a picture of chronic
daily headache. Thus, chronic migraine has the following characteristics: daily
or almost daily headache greater than 15 days a month. The patient suffers
from headaches at least 4 hours a day, and there is usually a history of episodic
CLINICAL CASES 163
migraine during this chronic phase. This transformation to a more chronic pic-
ture usually takes place over a 3- to 6-month period of time.
Chronic Tension Type Headache
Patients with a history of episodic tension headaches can progress to a more
chronic tension type headache. There is usually the absence of the typical fea-
tures of migraine except for nausea, which is usually not associated with vom-
iting. The patient usually is affected more than 15 days a month, with an
average headache duration of greater than 4 hours per day. The pain is usually
in the temporal region, described as a pressing or tightening, which is of
mild to moderate severity. It is often in a hatband distribution. There can be
associated pain and tenderness in the occipital area as well as in the posterior
strap muscles of the neck. These patients can also have an occasional break-
through migraine headache, but the dominant headache is clearly the more fre-
quent bitemporal headache.
New Daily Persistent Headache
New daily persistent headache is the acute development of a daily
headache over a short period of time, usually less than 3 days. There can be
a precipitating event, often an antecedent viral illness. Typically patients with
new daily persistent headaches are younger than those with chronic migraine.
Once the headache has begun, the average frequency is greater than 15 days
per month of headache, and the headache duration is usually greater than
4 hours a day if untreated. There is no prior history of tension type or migraine
headaches. The acute onset of headache which is present less than 3 days is
critical