An 18-year-old woman comes to the office due to recurrent headaches. In the past, the patient has had occasional headaches, especially during term exams or other stressful situations. However, over the past 3 months, she has had 4 episodes of severe headache. They are always left sided, throbbing, associated with nausea, and spontaneously resolve after 12-24 hours. The patient also reports feelings of numbness and tingling in her extremities prior to the headaches. She has no chronic medical conditions and underwent an appendectomy several years ago. The patient is sexually active with her boyfriend and began taking combined oral contraceptives 6 months ago. Vital signs are within normal limits. Physical examination, including neurological examination, shows no abnormalities. Which of the following is the best next step in management of this patient?

Question

An 18-year-old woman comes to the office due to recurrent headaches.  In the past, the patient has had occasional headaches, especially during term exams or other stressful situations.  However, over the past 3 months, she has had 4 episodes of severe headache.  They are always left sided, throbbing, associated with nausea, and spontaneously resolve after 12-24 hours.  The patient also reports feelings of numbness and tingling in her extremities prior to the headaches.  She has no chronic medical conditions and underwent an appendectomy several years ago.  The patient is sexually active with her boyfriend and began taking combined oral contraceptives 6 months ago.  Vital signs are within normal limits.  Physical examination, including neurological examination, shows no abnormalities.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

This woman with recurrent, unilateral headaches associated with nausea and paresthesia (ie, numbness, tingling) of her extremities has migraine with aura. Migraines are an episodic neurological disorder that results in severe, unilateral, throbbing headaches often associated with photophobia, phonophobia, and nausea/vomiting. Migraines typically last 4-72 hours, and women are affected more frequently than men. Up to 25% of patients also develop focal, reversible neurologic symptoms that precede or accompany the headache, known as an aura. Symptoms of aura may include visual (eg, wavy lines, visual loss), sensory (eg, paresthesia, numbness), auditory (eg, sounds, hearing loss), and motor (eg, tremors, weakness) dysfunction. Women with migraine, particularly those associated with aura, are at increased risk of ischemic stroke. This risk is magnified for patients on estrogen-containing contraceptives (eg, combined estrogen/progestin pill, vaginal ring, transdermal patch), which increase the risk of thrombosis by altering hemostasis. Therefore, estrogen-containing contraceptives are contraindicated in patients with a history of migraine with aura and should be discontinued immediately. (Choices A, E, and F) Further management of migraine includes abortive therapy (eg, nonsteroidal anti-inflammatory drugs, triptans) to treat acute attacks, and preventive medications (eg, selective serotonin reuptake inhibitors, propranolol) for those with frequent, debilitating symptoms. Although these options should eventually be considered for this patient, she is at elevated risk of stroke while on an oral contraceptive, and the prompt discontinuation of this medication should precede other management. (Choice C) Measurement of cerebrospinal fluid pressure is used to diagnose idiopathic intracranial hypertension (ie, pseudotumor cerebri), which causes headache and nausea in young (usually overweight) women. However, it is typically associated with diplopia and papilledema on exam. Aura (eg, paresthesia) is unexpected. (Choice D) MRI of the brain is indicated to evaluate for mass lesions, stroke, or transient ischemic attack. Although these can cause headache, a tumor usually causes neurologic deficits and progressive headache, whereas stroke typically causes negative symptoms (eg, weakness). Symptoms would not be expected to remit and recur every few weeks. Educational objective: Migraine is an episodic neurological disorder that results in severe, unilateral, throbbing headaches often associated with photophobia, phonophobia, and nausea/vomiting; they may be accompanied by aura (focal, reversible neurologic symptoms that precede or accompany the headache). Estrogen-containing contraceptives are contraindicated in patients with migraine with aura due to the increased risk of ischemic stroke.

An 18-Year-Old Woman Comes to the Office Due to Recurrent