Gaston Migraines Chief Complaint Ive been having really bad headaches that wont go away HPI Patient LR is a 28 year old Caucasian female that presents to the clinic with complaints ID: 627469
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Slide1
Migraine Headaches:
Dacy
GastonSlide2
MigrainesChief Complaint: “ I’ve
been having really bad headaches that won’t go away.”
HPI
: Patient
L.R
.
is a
28
year old Caucasian
female
that presents to the clinic with complaints
of headaches accompanied by nausea and sometimes sensitivity to light. The headaches are almost every other day, they last usually all day long and nothing alleviates them. They started about 4 months ago and have been getting worse. OTC Excedrin was the only thing that she has tried. Slide3
MigrainesPMH:
Anxiety/Depression-controlled being seen by psych Dr.
Family History
:
Father: Diabetes
, BPH
Mother
:
HTNSlide4
MigrainesMedications
:
1)
Wellbutrin 100mg
po
BID
2)
LoEstrin
28 1
po
q day
Allergies
: PCN
Surgical History
:
Gallbladder removal 2000 unremarkable
Slide5
MigrainesSocial History:
Denies recreational drug use, drinks 3x per week, usually on weekends. Lives with her boyfriend of 4 years, is finishing her undergraduate degree, has no children, exercises 4 times per week (jogging, treadmill), eats healthy diet.Slide6
Migraines (Review of Systems)General: denies fever, chills,
fainting.
HEENT
:
See HPI, denies
dizziness, vertigo, fainting or trauma. Last eye Exam was 6 months
ago-normal, PERLLA.
Denies changes in vision, pain, redness, double vision or discharge. Denies hearing impairment, tinnitus, earaches or infection.
Denies nasal discharge
, infection, nosebleeds or trauma.
D
enies
sore throat, voice changes, bleeding gums or hoarsenessSlide7
Migraines (ROS cont’d)Skin:
denies rash, itching, tingling, lesions or wounds
.
Neck:
denies dysphagia, tenderness, pain, or masses
Pulmonary:
Denies dyspnea, cough, sputum, hemoptysis, wheezing or asthma.
Cardiovascular:
Denies palpitations, orthopnea, edema or murmurs.
Gastrointestinal:
See HPI (nausea)
D
enies heart burn, reflux.
No change in stool pattern, denies blood-tinged stools, abdominal pain, constipation or diarrhea.
Extremities:
Denies coolness, tingling, loss of sensation or cyanosis.
Vascular:
Denies leg pain, swelling, leg cramps, ulcers or loss of hair on legs.
Urinary:
Denies burning, frequency, odor.
Musculoskeletal
:
Denies muscle or joint pain/tenderness/stiffness, muscle cramps, gout or weakness. Full ROM.
Neurological:
See HPI (headaches)
Denies
fainting, blackouts, weakness, paralysis, numbness, tremors, loss of memory, unsteady gait or speech disorders.
Endocrine:
Denies thyroid disorder, heat or cold intolerance,
changes in hair growth
. Slide8
Migraines (Physical Exam)Vital Signs:
BP
124/78
- HR
70
regular- RR
16
unlabored- Temp
98.2
– O2
100
%
Height:
5ft
6
inches
Weight:
124
BMI:
20.0-normal
General:
Patient is
pleasant 28
yr
old
Caucasian
female
who
appears to clinic in good spirits.
Sh
e
is AOx3, appropriately dressed and aware of
her
situation and surroundingsSlide9
Migraines (Physical Exam)HEENT: Head
nomocephalic
without
tinderness
, lesions or lumps. Hair evenly distributed, texture and quantity unremarkable. Facial features symmetrical an overall unremarkable, no weakness noted. PERRLA, EOM intact, Sclera clear, no redness or lesions present, conjunctiva pink without excessive vascularity. Cornea clear, no discharge or excessive tearing. Ear canals clear, no lesions or tenderness noted. Tympanic membranes bilaterally pearly gray with light reflex. No external exudate or bleeding.
Rhinne
: AC>BC bilateral. Webber: midline no lateralization. Nose symmetrical with no evidence of trauma. Nares patent, mucosa pink without discharge or swelling. Mouth mucosa moist, pink without lesions, tongue is midline, no coating or swelling present. Throat is moist, pink, uvula rises midline symmetrically with mild obstruction of uvula, gag reflex intact. Slide10
Migraines (Physical Exam)Neck: Full ROM, trachea midline, thyroid unremarkable, no lymphadenopathy.
Skin
:
Warm to touch, no cyanosis.
T
urgor
good, nail beds pink with good capillary refill.
Pulmonary:
Lungs clear bilaterally, no crackles,
ronchi
, wheezing or
rales
. Unlabored
symmetrical
respirations. Tactile fremitus normal intensity and equal bilaterally.
Percussion
resonant in all lung fields. Vesicular breath sounds heard throughout.
No
egophony
, whispered
pectoriloquy
or
broncophony
noted
Cardiovascular:
Examined seated and supine. No abnormal pulsations, thrills or heaves noted. S1 louder at apex, S2 louder at base. No extra heart sounds heard, no murmurs, rub or gallop. Slide11
Migraines (Physical Exam)Vascular:
No JVD. All pulses 2+ bilaterally in upper and lower extremities. No bruits h
eard
. Negative Homan’s sign bilaterally.
Abdomen:
U
nremarkable
to inspection, no visual abdominal pulsations.
Normoactive
bowel sounds in all 4 quadrants. Percussion dull from extra abdominal fat but noted throughout. Liver span normal, no
organomegaly
noted. No masses noted. No CVA tenderness noted. No bruit heard over aortic umbilicus. Scar noted from gallbladder removal, otherwise unremarkable.
Extremities
:
Capillary refill <1 second, no edema, no clubbing noted.
Full ROM bilateral upper/lower extremity
.
Musculoskeletal:
Gait
within normal limits, full ROM all extremities. Spine midline with no deviation, normal curvature. No joint or muscle pain.
Neurological:
AOx3 with no mental deficits noted. Cranial nerves intact. DTR’s intact,
2
+ upper and lower extremities. Sensory intact, no motor deficits noted. Gait normalSlide12
Migraines (Differentials/Diagnosis)Differential/Diagnosis:
1)
Migraines ICD-9: 346.00 (With/Without Aura/Chronic).
Chronic
migraine
is the most frequent complication of
migraine
. It is defined by the presence of headache on 15 or more days a month, of which at least eight must meet the criteria of
migraine without
aura
for a minimum of three months. In addition they must not be due to
medication abuse
or attributable to any other
cause
(
Carod-Artal
, F.,
Irima
, P.,
Ezpeleta
, D., 2012).
2)
Tension Headaches ICD-9: 307.81
3)
Cluster Headaches ICD-9: 339.00Slide13
Migraines (Plan)Plan
Management
of migraine is multifaceted and includes early
targeted and
multimodal approach for holistic treatment based on
bio-
psy
-
cho
-
ecological
nature. The first step in migraine management should be
1. Preventive treatment
2
. Acute treatment for pain treatment
(Singh, 2014)Slide14
Migraines (Management Cont’d)Prevention can be satisfactorily done by avoiding triggers migraine
producing
diet and drugs by pharmacological means and
keeping improved
health.
Treatment
of acute phase consists of pharmacological treatment
and alternative therapies.Slide15
Prevention of MigraineAvoiding triggers a) stress b) menstrual cycle in women c)
changing the
routine like sleep pattern or changing exercise pattern d)
avoiding the
changes in weather heat or high humidity and e) bright lights glare
or
reflected sunlight
Avoiding migraine foods
Chocolate, alcohol, particular wine, aspartame, monosodium
glutamate
,
fibre
, nitrates usually found in hotdogs bacon and
coldcuts
.
Tyramines
found in pickled or marinated food. Aged cheese and
yeast. Excessive
caffeine or caffeine withdrawal. Fasting or skipping meals.
Miscellenaous
triggers
Birth control pills, hormonal therapy, overuse of headache
medicine causing
rebound headaches, strong emotions like depression and
anxiety
(Singh, 2014)Slide16
Preventive pharmacotherapies come from following group of medications and have established and significant efficacy in helping migraine patients
I. Beta blocker e.g. Propranolol,
Metoprolol
,
Atenolol 2
.
Antiepileptics
e.g. Divalproex,
Topiramate
(Topamax) 3. Serotonin
antagonists
e.g.
Cyproheptadine
and
Pizotifen
(Singh, 2014)Slide17
MigrainesReferences:
Carod-Artal
, F.,
Irima
, P.,
Ezpeleta
, D. (2012). Chronic migraine: definition, epidemiology, risk factors and treatment
.
Neurology Review,
54(10),629-637.
Singh, A. N. (2014). Diagnosis and Management of Migraine.
International Medical Journal
,
21
(3), 255-257