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LEARNING OBJECTIVES

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After completing this case study, the reader should be able to:

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  • Develop pharmacotherapeutic goals for preventing and treating migraine headaches.

  • Provide appropriate pharmacotherapeutic recommendations for an individual patient based on the patient’s headache type and severity, medical history, previous drug therapy, concomitant problems, and pertinent laboratory data.

  • Educate patients on the use of abortive and prophylactic agents for migraine headaches and menstrual migraines.

  • Describe the appropriate use of a headache diary and how it may be used to refine headache treatment.

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PATIENT PRESENTATION

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Chief Complaint

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“This new medication is not working for my migraines. My headaches are worse around my period and I have gained 10 pounds!”

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HPI

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Sarah Miller is a 34-year-old woman who presents to the Neurology Clinic for a follow-up of migraine headaches. She states that she used to get about two migraines every month; however, she recently went back to work full-time and has two young children, ages 3 and 5, to care for. Since then, the frequency of her migraines has increased to about four to five per month. She states her migraines usually occur in the morning and are more frequent around her menses. Her typical headache evolves quickly (within 1 hour) and involves severe throbbing pain which is unilateral and temporal in distribution. Her headaches are preceded by an aura which consists of nausea and pastel lights flashing throughout her visual field. Photophobia occurs frequently, and vomiting may occur with an extreme headache. She reports experiencing severe migraine attacks that cause her to miss 1 day of work each month. She is unable to complete household chores and has a difficult time caring for her children on the days she has severe migraine attacks. She also complains of having mild migraine attacks lasting 3 days per month during which her productivity at work and at home is reduced by half. She typically has to retreat to a dark room and avoid any noise, or the severity of the migraine increases. She rates her migraines as 7–8 on a headache scale of 1–10, with 10 being the worst. At her previous visit to the Neurology Clinic 3 months ago, she was prescribed naratriptan 2.5 mg orally to be taken at the onset of headache. However, naratriptan has not been effective for half of the migraines she has had in the last 3 months. During two of the attacks, she experienced partial pain relief, with the pain returning later in the day. She mentions that she was prescribed naratriptan when the Cafergot she was taking stopped working. She states she has taken her medications exactly as advised. She prefers to use medications that can be taken orally. She was started on valproic acid at her last clinic visit for headache prophylaxis and has noticed a 10-lb weight gain. She inquires about switching from valproic acid ...

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