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Key Clinical Questions

  • image Are there warning signs of a secondary headache that would require further imaging?

  • image Is the headache new or different?

  • image Is the headache brought on by exertion, sexual intercourse, coughing, or sneezing?

  • image Is the onset of the headache sudden or severe?

  • image Did head or neck trauma precede the headache?

  • image At the beginning of the headache syndrome did the patient have any neurologic symptoms other than visual symptoms?

CASE 89-1

A 25-year-old, right-handed woman with a 3-year history of headaches is admitted to the hospital for “pain control.” In the emergency department, she had a negative noncontrast head computed tomographic (CT) scan and was prescribed intravenous hydromorphone (Dilaudid).

Does the patient have any other medical problems or risk factors for intracranial pathology?

Her past medical history and review of systems is otherwise negative. Her family history is positive for migraine.

What factors worsen the headaches?

Tension and stress triggered her headaches, typically worse 2 or 3 days before her menstrual period begins. Alcohol, chocolates, and peanuts may aggravate her headache. She tried stopping the oral contraceptive and noticed no improvement in her headaches. Social history reveals that she is single and disabled from her headaches.

What medications has she tried?

She has tried many different medications, including analgesics, antidepressants, calcium channel blockers, and β-blockers. The only medications that help her are sumatriptan taken subcutaneously and narcotics, currently hydrocodone at least one tablet a day. She has been taking alprazolam 10 mg three times a day for a couple of years. She also uses promethazine for nausea. Recently she is beginning to have daily headaches and has to make trips to the emergency department to get shots of meperidine.

What has been her workup to date?

She has seen multiple neurologists. She has been treated with biofeedback and has seen psychologists. She had multiple CT scans and magnetic resonance imaging (MRI) of her head.

Does she appear acutely ill?

On examination she is a well-developed, well-nourished, young woman in no acute distress with normal vital signs. Her general physical examination is normal and noncontributory.

Is she confused?

Her mental status is normal and she does not appear intoxicated.

Does she have a “nonfocal” neurologic examination?

No bruits are heard over the orbits, cranial vessels, or temples. Cognitive function, language, and memory are all intact. Her cranial nerve examination is completely normal, including sharp optic discs and normal visual fields. She does not have meningeal signs. Her motor exam shows full and equal tone, power, and bulk in all four extremities. Her sensory exam is intact for all modalities, and the Romberg test is negative. Tests of coordination in the upper and lower extremities are all normal. There is no evidence of cerebellar dysfunction. Her gait and stance are normal, including tandem gait. Her reflexes are average in amplitude and equal bilaterally; both plantars are flexor. No pathological reflexes are elicited.


Almost certainly too much medication has ...

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