Janet’s History of Migraines

Janet reported struggling with severe headaches that were not responding to treatment. She had been dealing with these headaches since childhood, but they became more intense and frequent when she was 22. Her symptoms typically involved throbbing pain on one side of her head, usually starting in her forehead and sometimes spreading to her neck. These headaches could last up to 48 to 72 hours. Before these symptoms occurred, she reported frequent yawning. During the attacks, she became sensitive to light and sound and usually felt nauseous afterward, although she did not vomit often. Her usual medications, ibuprofen and acetaminophen, provided no relief. On average, Janet experienced about 13 headache days per month, each lasting around 12 hours and scoring nine out of ten for pain severity on a scale.

Janet had a history of brain surgery to remove a tumor in her fourth ventricle when she was 19, and she believed this surgery weakened her neck muscles, which she thought might have contributed to her headaches. Janet’s headaches were not linked to her menstrual cycles, and she had no history of neck injuries or dental problems. She denied any history of psychiatric problems such as depression or anxiety.

The Workup of Migraines

Diagnosing migraine headaches is challenging, as there is no brain imaging or blood test that can definitively reveal the diagnosis. The patient’s history is most likely to point to migraines. Janet’s story was typical for migraines; however, it is essential to rule out other causes, including severe diagnoses like tumors.

Based on her history, I could rule out ordinary or “cluster” headaches. It is important to note that migraines are not simply terrible headaches. Janet’s history of experiencing an “aura” (her yawning) is typical of migraines, as are the location, spread, and duration of her headaches.

She had no pain in her sinuses or temporomandibular joint (TMJ, where her jaw hinge is located). Chronic sinusitis and TMJ syndrome can sometimes be mistaken for migraines. A healthcare provider must rule out these diagnoses with a physical examination.

Finally, I performed a neurological examination as thoroughly as possible without special equipment. Janet’s examination showed no signs of neurological abnormalities. If there had been any such signs, I would have referred Janet immediately for brain imaging, such as computed tomography (CT), and referred her to a neurologist.

I do not send every patient with headaches for a CT scan. Doing so would be time-consuming and anxiety-provoking, not to mention expensive. If I were unable to determine the source of Janet’s headaches or treat them effectively, I would immediately refer her to a specialist, who may or may not order brain imaging.

Migraine Treatment with Sumatriptan

I prescribed sumatriptan nasal spray 10 mg to Janet. I instructed her to use the spray whenever she felt the aura of a migraine coming on, especially if she started yawning when she was not tired. I recommended that she gently blow her nose before using the single-dose spray. I informed Janet that it is normal to feel a bit strange during the first hour after taking the medication and that she might feel drowsy in the following hours. I also advised her that she might experience mild and temporary pressure or discomfort in her chest and throat. If she felt dizzy, nauseous, or vomited, I instructed her to call me immediately.

Victory Over Migraines with Sumatriptan

I called Janet a month later. She reported having five episodes and only one migraine that month, which occurred when she was out of the house and had forgotten to take her sumatriptan nasal spray. The other episodes were successfully interrupted by the medication. After the first dose, she felt dizzy and tired, but these symptoms were short-lived. Janet did not report nausea or tightness in her throat or chest.

Janet and I both celebrated this victory over her migraine headaches. As a follow-up, I encouraged Janet to think about triggers for her migraines and how she might avoid them. Janet mentioned that eating chocolate was probably one of her triggers but that she did not want to deny herself one of life’s pleasures. However, she agreed to reserve chocolate for special occasions and to keep her sumatriptan nearby.

Because migraines can be debilitating and chronic headaches can be a sign of a severe illness, it is essential that you and your loved ones seek medical attention promptly if you believe you have migraine headaches, if your migraine treatment is not working, or if you have any questions or concerns.