Neurology Clerkships
Case 24  
Author: Eric Kraus, MD
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This is a 29 year-old female referred by Dr. Jones for consultation concerning headaches. The patient is the only history-giver today.

The patient started getting headaches twelve years ago. This was during the pregnancy of her first child. A typical headache is present when she wakes up in the morning and is throbbing. It may be left-sided, right-sided, or bilateral. She does get nausea, photophobia, sonophobia, and vomiting. The duration is one to four days and the frequency is two to three times per month. She has never kept a headache diary to understand triggers or true frequency.

Medications that she has tried over the years include Imitrex, DHE, Excedrin migraine, Midrin, Cafergot, Fiorinol, Maxalt, Zomig, Percocet, and prednisone. None of them have ever worked except Percocet will reduce the pain a little bit.

The patient quit her job two months ago because of stress. She has three children, ages 7, 10, and 12, with the oldest also having headaches. Her husband is a fisherman and goes away for long periods of time. Their marriage is in trouble. She denies any other stresses, family conflicts, or depression.

She believes a CAT scan of her head was done two to three years ago and normal.

1. Asthma.
2. Sinus surgery 1999
3. Obesity

1. Percocet 5mg 2 po prn headache
2. Albuterol and Salmeterol MDI
3. MVI

Allergies: NKDA

Family History: Positive for migraines in her father. Mother has depression.

Social History: 3 children. Two glasses wine with dinner. 1 ppd.

BP 122/82   HR 80   T 36.8°C   W 258lb
General: Sighs multiple times every minute.
Mental Status: A + Ox3
HEENT: Atraumatic. PERRLA, EOMI, no nystagmus. Fundi reveal sharp discs with good venous pulsations. Face is normal to motor and sensory exam. Nose normal. Hearing intact. OP normal.
Motor (Power/Tone/Bulk): 5/5 all. Tone and bulk normal.
Sensory: Normal vibration at the toes.
Reflexes: 2/4 at biceps, triceps and ankles, 1/4 at brachioradialis and knees. Both toes downgoing.
Coordination: Normal FNF and HKS
Gait: Mild wide base consistent with weight.
Abnormal Movements: None
Other Organs: Carotid auscultation normal. RRR w/o murmur.

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