Case presentation ---------------------- A 30 year old left handed female with a history of headaches is referred to the neurology clinic for evaluation of headaches. She is currently 23 weeks pregnant. She has had on and off headaches since the age of 14. Her typical headache happens about 2-3 times a week and is unilateral and associated with nausea. Does not usually have any vomiting. She describes it as severe in intensity and throbbing in nature and physical activity increases the headache. She was on Trokendi XR and Celexa everyday. She usually takes Ibuprofen 600 mg for her headache prescribed by her PCP which she takes every 6 hours during an attack and it controls her headaches well. She does not have much photophobia. But she has osmophobia and phonophobia. Typically her headaches last for about 5-24 hours without treatment. She has no triggers for her headache except for working on the computer for long hours as part of her job. 3 weeks ago she got a home pregnancy test which came back positive and she has started taking Prenatal vitamins and DHA and the PCP discontinued the Ibuprofen, Celexa and Trokendi XR and she now uses Acetaminophen as needed. 9 weeks into her pregnancy she has been experiencing increasing headaches. She gets her typical headache every 2 days and she uses abortive therapy successfully as shown above. In the last 14 weeks she has a headache everyday that is bilateral and intense dull aching in nature. Abortive medication takes the edge off of the pain but it recurs in about 6 hours. Due to this increase in headaches and change in the nature of her headaches, the patient is referred to neurology clinic. She has no focal neurological symptoms and no visual symptoms. Her headache does not get better on sitting up and does not get better on lying down. No cognitive changes and no seizures. On exam her BP is 135/89. Neurological exam is essentially normal except for positive Tinels sign on the left wrist (negative Phalens sign and negative spurlings sign). Food for thought - What is the most likely cause of the headache? How do you treat this? what was the risk of continuing the pre-pregnancy set of medications (aka why did the PCP discontinue the medications)? This is not for the advanced neurology resident - more for the juniors as the answers could be very obvious to the seniors... Hoping for some constructive discussion about this case ;)
Posted on: Fri, 14 Mar 2014 03:21:47 +0000
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