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Case: Just Another Migraine?

by Charles Vega, MD
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    00:01 Okay, last case.

    00:03 So, we’ve got an older patient here.

    00:05 I’ve got a 75-year-old woman.

    00:06 She has a one-day history of headache.

    00:08 Well, it’s just one of my migraines, she explains.

    00:11 Sounds pretty benign.

    00:12 Let’s get a little bit more.

    00:15 So, she has a long history of unilateral migraine headaches, which previously resolved with just a high-dose non-steroidal anti-inflammatory drugs.

    00:24 However, the character of this pain is different.

    00:26 It’s very concentrated over her temple specifically and it's actually tender to palpation there.

    00:34 So, just with that limited history alone, what's the next best step in the management for this patient? And again, you could pause and think about this for a second.

    00:44 So, is it, A, just change the type of NSAID she is taking? Maybe that will make a difference.

    00:49 Just reassurance.

    00:50 She's right, it’s probably just a recurrent migraine and just continue with that expectant management that’s been working for a while.

    00:56 Do you initiate maybe a new drug, like a triptane instead of giving her an NSAID? Maybe that’ll be more effective for a migraine headache? Or, D, do we send her to the laboratory immediately and we also initiate corticosteroids? So, this one is to throw you off.

    01:11 Indeed, not every case of acute management just needs reassurance and it will probably resolve with time because this is unusual.

    01:21 New headaches and different types of headaches always should raise attention for potential red flags.

    01:27 In this case, you're seeing unilateral temporal-based pain in a 75-year-old woman with the area actually tender to palpation.

    01:35 All of that is very concerning for the diagnosis of…temporal arteritis.

    01:41 Very good.

    01:42 So, temporal arteritis can have severe complications, particularly in terms of risk of thrombosis and ischemia immediately, so she could lose her vision, she can have a stroke.

    01:54 Therefore, immediate laboratory evaluation for simple things like a Sed rate and a CBC for the potential for temporal arteritis and she should not leave your clinic without a prescription for corticosteroids because the application of corticosteroids can dramatically reduce that risk of complication.

    02:12 So, she’ll need close follow-up and an initiation of treatment right away.

    02:17 So, this is just an example, but I thought it was a keen example to give you an idea that not every case can be managed just with expectant management and reassurance.

    02:27 But, certainly, I think for USMLE exam and the way I think about patient care, the answer many times, it's not every answer, and so the trick for you is to watch for high-risk conditions.

    02:38 Now, what do those conditions include? I think headache is a high-risk condition.

    02:43 So, always pay attention to it.

    02:44 Chest pain, while it’s usually benign, still a high-risk condition.

    02:48 New neurological symptoms.

    02:50 This isn’t the patient with diabetes for 20 years, who has bilateral tingling in the feet, but I’m talking about somebody who has monocular blindness or a left facial droop, something new going on that's acute.

    03:05 Think about stroke, you think about masses or other severe CNS disorders.

    03:11 Or – and these are often found incidentally – new lesions or masses in organs such as the skin or the breasts.

    03:17 I’ve got this mole and, yeah, it seems to be growing and changing.

    03:20 Then it bleeds and falls off and then it comes back again.

    03:23 The first thing I'm worried about is cancer.

    03:25 Now, that's – is it going to be cancer? Unlikely.

    03:29 But the first thing I'm going to worry about is cancer.

    03:32 And anytime somebody comes in with a – I feel a new mass in my breast, particularly if they’re over 50 and particularly if they are higher risk for breast cancer because of a family history or something like that.

    03:43 These are the high-risk conditions just to name a few.

    03:46 But some of the more common ones that we see should alert you to the fact that you might need to really go and perform a more thorough workup here.

    03:55 You may need to order advanced therapy for this patient right from the get-go, not everything can just be a wait-and-see approach.

    04:02 So, hopefully, you found these cases beneficial.

    04:05 Now, we’ll move into the acute care module and you can see how this plays out with some real cases.

    04:10 Thank you.


    About the Lecture

    The lecture Case: Just Another Migraine? by Charles Vega, MD is from the course Acute Care.


    Included Quiz Questions

    1. Discuss avoiding activities that aggravate pain and send home with a night wrist splint
    2. Obtain an MRI of the neck
    3. Refer to hand surgeon
    4. Check HgA1c
    5. Obtain labs for erythrocyte sedamentation rate and rheumatoid factor
    1. Order an emergent spinal MRI and surgical evaluation
    2. Report the patient for malingering
    3. Ask the patient to obtain an early refill of her narcotics from the provider that she has signed a pain contract with
    4. Give the patient a 1-week refill of narcotics and send a message to her primary care provider to follow up
    5. Increase the patient's narcotic dosage, as her back pain is clearly progressing
    1. Incontinence
    2. Lower back pain
    3. Radiation of pain into legs
    4. Fatigue
    5. Age and gender
    1. Excisional biopsy in clinic today and await pathology
    2. Prescribe hydro-cortisone cream for the itching
    3. Reassure patient that it is a benign lesion and advise him to avoid scratching it
    4. Schedule for a re-check in 3 months time to monitor for any changes
    5. Advise patient to use moisturizing sun-cream and follow up if he notices any further changes in the size of the mole

    Author of lecture Case: Just Another Migraine?

     Charles Vega, MD

    Charles Vega, MD


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