Management of Migraine Headaches

Carlos - headache sufferer

Case study: When you start clinic this morning, you see your first patient is a new patient with a chief complaint of “headaches.” Upon entering the exam room, you see a young man in no apparent distress, scrolling through his phone. He stands up to greet you and introduces himself. Carlos is a 25-year-old man who describes himself as very healthy. He comes to the clinic today because he has been having frequent headaches, and they are interfering with his work. What do you ask Carlos?

You ask Carlos to tell you more about his symptoms. He tells you that he experienced intermittent headaches in the past and ibuprofen managed his symptoms. However, he has recently been experiencing an increase in frequency of headaches to the point where he is having severe headaches three or four times per week. The headaches began a few months ago. His headaches involve throbbing pain on one side of his head associated with nausea and light sensitivity. These headaches last for four to six hours and sometimes his head hurts so badly he can feel tears in his eyes. Carlos had an episode of head trauma three weeks ago while boxing, a hobby he has pursued for the past decade. However, he had been having more frequent headaches before the head trauma. What else do you want to know?

Before doing a physical exam, you ask Carlos about his past medical history. He tells you he has not had any medical or surgical problems in the past, except for acne as a teenager. He is not taking any prescribed medications, although he does take creatine powder as part of his weight-lifting regimen. He denies the use of anabolic steroids, illicit drugs, alcohol, or tobacco. He stopped drinking alcohol because he had headaches afterwards. He has been taking NSAIDS for his headaches several times a week. He does not have any allergies. Carlos works as an investment banker, and he has been experiencing large amounts of stress lately. He tells you that he has been having bouts of insomnia and some heart palpitations during the day. On physical exam, his vital signs are normal, his heart rate and rhythm are normal, his breath sounds are clear bilaterally, and he does not have any abdominal tenderness. His neurological exam is completely normal.

You suspect that Carlos has migraine headaches. He has some of the classic symptoms of migraines, including throbbing, pulsatile headache, associated nausea/vomiting, and sensitivity to light. He does not appear to have any auras. Carlos also has some risk factors associated with onset of migraines. Migraine headaches are often associated with stress, poor sleep habits, and anxiety. Although migraines occur twice as commonly in women than in men, migraines are fairly common recurrent headaches in the general population. What do you do next?

You suggest Carlos start keeping a headache journal to see if he can pinpoint exacerbating and relieving factors. You also suggest he start taking steps to relieve some of his stress, improve sleep, and decrease anxiety. These treatments may include starting cognitive behavioral therapy, avoiding working late into the night, and taking up meditation and yoga. He should also try to see if certain foods impact his headaches. In terms of treatment, you recommend rest, NSAIDS, acetaminophen, and over-the-counter triptans. However, he should not take these medications for more than ten days per month. If his headaches become worse or do not improve, he should return to clinic for a follow-up appointment.

How do you manage your patients with migraine headaches?

Dr. V. Silverstein
Durham, NC

Published on 10/31/18