Case: 67-year-old Woman with History of Migraines

by Roy Strowd, MD

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    00:01 In this lecture we'll talk about headaches that present with prominent visual disturbance.

    00:06 Let's start with a case.

    00:08 This is a 67-year-old woman who has a history of migraines until menopause.

    00:14 She now presents with two months of new chronic daily headache as well as tenderness in the scalp and shoulder aching, and a 15-pound weight loss.

    00:24 Yesterday she has an episode where she was completely unable to see from her right eye, in other words, transient monocular vision loss.

    00:32 Her exam is now normal. What type of headache syndrome is this? Well, there's a number of key features that we're seeing here that we should associate with this headache syndrome.

    00:44 This patient has scalp tenderness, myalgias, and weight loss.

    00:47 This makes us concerned about some underlying inflammatory or other underlying condition that may also be presenting with headache would be the root cause of this headache syndrome.

    00:59 Importantly, this patient presents with headache with vision dysfunction, and here we have a patient with transient monocular vision loss which points us to think about this category of headache conditions, headache with visual dysfunction. Is this a primary or secondary headache syndrome? Well, headache was a vision dysfunction points us in the direction of secondary headache syndrome and this requires urgent management and evaluation.

    01:28 So what's the optimal management and evaluation for this headache? Should we, one, get an immediate CT of the head without contrast or test erythrocyte sedimentation rate and see how C-reactive protein for giant cell arteritis.

    01:43 Refer to ophthalmology to evaluate for ocular etiology or perform an MRI of the brain.

    01:49 Oh, we have visual disturbances, we might think that referral to ophthalmology is the first step, but that's not the first step for evaluating this patient.

    01:57 If this patient does in fact have giant cell arteritis, which I would be concerned about, this requires prompt treatment prior to consideration of temporal artery biopsy, so the first step is to evaluate the giant cell arteritis.

    02:11 They are in a clinic or emergency department, and ophthalmologic involvement may be considered urgently within the next several weeks.

    02:20 Should we perform an MRI of the brain? That may be needed, but again, not the first step for the evaluation and management of this patient.

    02:28 Head CT is important for thunderclap headaches.

    02:32 Patients who have possible subarachnoid hemorrhage, an imaging may be needed for this patient but this is not the first and most appropriate step for this patient.

    02:42 Testing of erythrocyte sedimentation rate and C=reactive protein is the best first step, and that's the right answer here.

    02:49 This is indicated for patients greater than 50 years of age who have a new onset of headache or a change in their typical headache pattern and vision loss.

    02:58 So that's what we would do for this patient.

    About the Lecture

    The lecture Case: 67-year-old Woman with History of Migraines by Roy Strowd, MD is from the course Headache.

    Included Quiz Questions

    1. Lab testing
    2. CT brain
    3. MRI
    4. Lumbar puncture
    5. Temporal artery biopsy
    1. It is almost never seen before age 50, with a peak incidence in ages 70–80.
    2. Men are affected more frequently than women.
    3. Patients with migraines in young adulthood do not develop giant cell arteritis later in life.
    4. It presents with an acute and abrupt onset of headache.
    5. It is a primary type of headache.

    Author of lecture Case: 67-year-old Woman with History of Migraines

     Roy Strowd, MD

    Roy Strowd, MD

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