A 15-year-old girl is brought to an urgent care clinic for evaluation of a headache that began 12 hours ago. Yesterday, the patient underwent a tonsillectomy and adenoidectomy for obstructive sleep apnea. The surgery was uncomplicated, and she was discharged home last evening. The patient has been sipping clear fluids and taking acetaminophen every 4-6 hours. However, she developed a dull, left-sided headache before falling asleep last night and woke this morning with throbbing pain near her left temple. The headache is similar in quality to those she has experienced since age 12. Vital signs are normal. BMI is 31 kg/m². The patient appears uncomfortable and holds her head in her hands but is alert and oriented. Cranial nerves II-XII are intact. Photophobia is present, and funduscopic examination is normal. Oropharyngeal examination reveals bilateral fibrin clots coating the tonsillar fossae, findings consistent with a normal postoperative course. Cardiopulmonary examination is normal. Neurologic examination shows normal tone, strength, and gait. Which of the following is the best next step in management of this patient?

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Explanation: 11ec25c8_d5de_d46e_bc81_9fa15fd883f1_MD0003_00 This patient has episodic, unilateral throbbing pain consistent with migraine headaches. Pathogenesis involves abnormal trigeminovascular system activation and release of calcitonin gene-related peptide (CGRP), a neuropeptide involved in pain signaling. Triggers include stress, fasting, dehydration, menses, and sleep deprivation. This postoperative migraine was likely triggered by inadequate hydration (eg, fasting prior to surgery and now only sipping of fluids). The classic presentation of migraines includes episodic, unilateral headaches with a throbbing or pulsatile quality. Headaches typically last <24 hours but may persist for up to 3 days. Nausea, vomiting, phonophobia, and photophobia are common. Some patients have a preceding aura (eg, scintillating scotoma, facial numbness). scintillating scotoma Migraine is a clinical diagnosis and does not warrant diagnostic evaluation (eg, neuroimaging) if the neurologic examination is normal. First-line treatment includes supportive care (lying in a dark, quiet room) and simple analgesia (eg, acetaminophen), which this patient has been using without relief. Refractory headaches are typically treated with a triptan (eg, sumatriptan), which is a serotonin receptor (5-HT_1B/1D) agonist that decreases neurogenic inflammation and CGRP release. Antiemetics (eg, promethazine) and dihydroergotamine are additional therapies for persistent headache. (Choice A) The treatment for cluster headaches is 100% oxygen via nonrebreathing mask or a triptan. In contrast to this patient's migraine, cluster headaches present with multiple bouts of pain, each lasting minutes to <3 hours. In addition, they occur with autonomic symptoms (eg, ptosis, tearing, nasal congestion), which are not present in this patient. (Choice B) Meningitis can present with severe headache and photophobia and is treated with urgent antibiotic therapy. However, unlike in patients with migraine, those with meningitis are typically febrile with meningeal signs (eg, nuchal rigidity). (Choice C) CT scan of the head is warranted for headache with features concerning for a mass (eg, focal neurologic deficit, ataxia) or increased intracranial pressure (eg, hypertension, papilledema). This patient's vital signs and neurologic examination are normal. (Choice E) Although only a temporizing measure, removal of cerebrospinal fluid via lumbar puncture can transiently relieve pain in patients with idiopathic intracranial hypertension. This condition classically presents in overweight young women with a headache often similar in quality to migraines. However, papilledema would be expected on examination. Educational objective: Migraines are classically episodic, unilateral, throbbing headaches commonly triggered by stress, fasting, and/or dehydration. Acute management includes simple analgesia (eg, acetaminophen) and a triptan (eg, sumatriptan) in refractory cases. References: Pharmacological treatment of acute migraine in adolescents and children. (http://www.ncbi.nlm.nih.gov/pubmed/23575981) Drugs for the acute treatment of migraine in children and adolescents. (http://www.ncbi.nlm.nih.gov/pubmed/27091010)

A 15-Year-Old Girl Is Brought to an Urgent Care Clinic