Question

A 24 year old woman with a history of recurrent headaches returns for follow up. For the past year and a half, she has experienced severe headaches accompanied by nausea and vomiting several times per week. Her pain is pulsating and throbbing, and typically affects the left temporal region of her head. The headaches last at least several hours, but have lasted as long as three days and have required her to miss several days of work. Past medical history is significant for major depression and dysmenorrhea. Her mother has a history of similar headaches. Several weeks ago, she was seen and given a prescription for oral sumatriptan. Today, she states that she continues to have several headaches each week, just as she did previously, but taking sumatriptan and lying in a dark room helps relieve them within a few hours. Her neurological examination is normal. There is no papilledema. Which of the following is the most appropriate step in the management of this patient?

A. Inhalation of 100% oxygen
B. Head CT with and without contrast
C. Lumbar puncture
D. Amitriptyline
E. Intranasal dihydroergotamine

Answer 1

The most appropriate step in managing this patient's frequent migraine attacks is to begin a prophylactic treatment with amitriptyline, given its beneficial effect on reducing migraine frequency and treating coexisting major depression.

Step-by-step explanation:

The patient's clinical presentation is highly suggestive of migraines, given the severe, pulsating headaches with accompanying nausea, vomiting, and unilateral location, and presence in her family history. Additionally, the sumatriptan response indicates that her headaches are indeed migrainous. Considering her case, the most appropriate next step in management would be the initiation of a prophylactic treatment to reduce the frequency and severity of her migraine attacks. Amitriptyline, a tricyclic antidepressant, is commonly used for migraine prophylaxis and has the added benefit of treating her coexisting major depression. Other options such as inhalation of 100% oxygen, CT scan, lumbar puncture, and intranasal dihydroergotamine are not indicated in this scenario as first-line management for frequent migraines with a normal neurological examination and no evidence of papilledema.