What’s Your Diagnosis? Migraine and Other Primary Headaches

Welcome to this month’s What’s Your Diagnosis Challenge!

But before we begin, check to see if you got the previous case on Emergency Department Management of Patients With Rectal Bleeding correct.

Case Presentation: Evidence-Based Emergency Department Management of Migraine and Other Primary Headaches  

A 36-year woman presents with a pounding left-sided headache associated with nausea that has persisted for 12 hours… 

  • She reports having similar headaches about twice monthly, and though they usually resolve with sumatriptan, she typically visits the ED about once a year for refractory events. This headache began gradually 12 hours prior and, despite use of oral sumatriptan 100 mg, ibuprofen 800 mg, and acetaminophen 1000 mg, it has not improved. 
  • Her physical examination is unremarkable, including normal vital signs, a normal fundoscopic and visual field examination, and a normal neurologic examination. A point-of-care urine pregnancy test is negative. 
  • You administer metoclopramide 10 mg IV and ketorolac 15 mg IV, but she reports only minimal relief. You wonder what your best next treatment option is… 

Case Conclusion

You determined that this patient had no risk factors for intracranial pathology, so a diagnostic workup was not appropriate, even though she did not respond to first-line management. The 1 atypical feature in her presentation was that she did not respond to metoclopramide + ketorolac, a regimen that is effective at relieving headache and associated symptoms in the vast majority of patients with migraine.

You ordered another dose of 10 mg IV metoclopramide, combined with 1 mg IV dihydroergotamine, and you added 10 mg IV dexamethasone to prevent recurrence of headache the next day. When she improved, you advised her to continue to use 100 mg oral sumatriptan, 600 mg oral ibuprofen, or the combination of the 2 for any migraine recurrence. You cautioned her not to use sumatriptan within 24 hours of taking dihydroergotamine, and you discharged her with primary care follow-up. 

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Last Updated on November 29, 2023

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