Chapter 26: Headache Disorders & Neurologic Pain Syndromes
A 34-year-old obese woman presents to her neurologist for disabling headaches that occur 4 times per month. The headaches started when she was 19 and have not changed in character. She has severe unilateral throbbing that is accompanied by nausea and vomiting. She does not have phonophobia or photophobia, and the headaches are not preceded by neurologic symptoms. The headaches are worse with movement. She has a history of asthma, which is well controlled, but otherwise, her history is unremarkable. Her neurologic exam, which includes funduscopic exam, is normal. What would be the best preventive medication in this patient?
A. The patient has episodic migraine without aura. Given her obesity and no history of renal calculi or glaucoma, topiramate would be the treatment of choice. Propranolol is contraindicated in patients with asthma. Acetazolamide is used for idiopathic intracranial hypertension. Sumatriptan is a migraine abortive treatment.
A 23-year-old woman presents with headaches that occur once every other month. Prior to the onset of headache, she sees flashing lights for about 15 minutes. The headache starts as a pressure pain and climaxes over 45 minutes to become throbbing and severe over the right or left frontotemporal region. She prefers to lay down in a dark and quiet room. She has no nausea or vomiting. A diagnosis of migraine with aura is made, and she is started on sumatriptan. The medication is effective at aborting her headaches because it works at which by which of the following mechanisms?
A. Agonism of serotonin (5-HT) 2B/2D receptors
B. Antagonism of 5-HT 2B/2D receptors
C. Agonism of 5-HT 1B/1D receptors
D. Antagonism of 5-HT 1B/1D receptors
E. Antagonism of 5-HT 2A/2C receptors
C. This patient has episodic migraine with aura and should be treated with migraine-specific therapy in the setting of no contraindications. Triptans work via agonism of 5-HT 1B/1D receptors. The 5-HT 1B subreceptor is thought to decrease nociception via vasoconstriction of vessels that mediate pain. The 5-HT 1D subreceptor inhibits trigeminal neuromediator release and activation of the trigeminal vascular system. This leads to decreased neurogenic inflammation, peripheral and central sensitization, and headache.
A 44-year-old man presents with severe pain that wakes him up in the middle of the night, around 11:00 pm and again at 1:00 am. The pain ...