Neurology Clerkships
Case 23  
Author: Eric Kraus, MD
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This is a 30 year-old male self-referred for 5 years of headaches. A cycle occurs once per year and lasts between 6 to 10 weeks. Each headache is always centered in his right eye, and he will have nasal congestion. He has not noticed any ptosis, pupil change, swelling in his face, or redness. The headache lasts between 30 and 50 minutes and usually occurs one to three times per day. Triggers include alcohol and spring is a common time of the year. The most recent cycle started 5 days ago.

In the past he has treated these headaches well with Verapamil and subcutaneous Imitrex. The Verapamil usually takes the headaches away very quickly. He will continue the drug for 6 weeks and then taper off. If the headaches come back as he is tapering the Verapamil he will increase it for two more weeks and taper again more slowly. The Imitrex subcutaneous works in about five minutes.

1. Hyperlipidemia

1. Verapamil SR 120mg qd
2. Imitrex SQ 6 mg prn

Allergies: PCN - rash

Family History: Positive for migraine headaches in his mother, sister and maternal grandfather. Father has ASCVD starting at age 52. Hyperlipidemia in many people.

Social History: No alcohol for 4 years. Non-smoker. Mechanical engineer. Married with 2 children.

BP 128/64   HR 88   T 37.0°C
General: Overweight Caucasian male in mild distress.
Mental Status: A + Ox3
HEENT: Atraumatic. PERRLA, EOMI, no nystagmus. Fundi reveal sharp discs. Face is normal to motor and sensory exam. Nose normal. Hearing intact. OP normal.
Motor (Power/Tone/Bulk): 5/5 all. Normal tone and bulk.
Sensory: Normal vibration at the toes.
Reflexes: 2/4 at biceps, triceps and ankles, 1/4 at brachioradialis, 3/4 at knees. Both toes downgoing.
Coordination: Normal FNF and HKS
Gait: Narrow based.
Abnormal Movements: None
Other Organs: Carotid auscultation normal. RRR w/o murmur.

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