CASE VIGNETTE “Then I can’t see and I start to panic. How am I going to work? How am I going to get home?” Theresa, a 26-year-old unmarried administrator, How often do you get these headaches? Mother has migraine and depression. presents with severe headaches accompanied by Has their severity or frequency changed? vision problems. She has had several consultations Began at age 13 years; occurred 3-4 times per year. You are worried about your job, and you in the past and is currently taking propranolol (20 In the past, vomiting always relieved the headache. also feel depressed at times. Is your mg/day) as prophylaxis. However, attacks have Headaches gradually worsened over the years. First social or family life affected? Are you become more frequent. Vital signs and physical consulted doctor at age 18 years and was prescribed able to enjoy yourself? examination are normal. oral ergotamine (Cafergot). The medication made Leads full, active social life except when she has a her nauseated, and she had cramps in limbs. headache bout. In probationary period with new Tell me about the vision problems, Cafergot was discontinued and she was started on job, which she enjoys. Lives in apartment with Theresa. What happens to your vision propranolol 20 mg daily. Gradually became roommate. Both parents live locally. One sibling, a and how long does the problem last? headache-free. She subsequently developed dysmen- sister. Family ties close. The vision problems warn her that a severe orrhea and was treated with oral contraceptives headache is developing. She first notices that any (OCs). Dysmenorrhea lessened but headaches Aside from these severe headaches, do bright light “catches her eye.” Then a diagonal returned; OCs discontinued. Isolated attacks of you have other headaches that also need band, mainly on the right side, slopes down across migraine recurred. They were unrelated to periods attention? her vision “colored like a rainbow with sparkles.” and always accompanied by visual problems. She has mild headaches that can be either ignored The bands multiply until almost all vision, mainly Restarted propranolol. Attacks have become more or easily controlled with 1-2 acetaminophen tablets. on the right side, is gone – she can’t read or see to severe and frequent. She was off work 2-3 days and They do not interfere with work and are attributed to drive. These take 10-15 minutes to develop. The is worried that she may lose her new job. stress or fatigue. headache starts in 30 minutes and the vision prob- lem fades in 2-3 minutes, but vision remains How do you manage during these Does anything seem to trigger your blurred for sometime. lengthy attacks? What do you do to try severe headaches? to get relief? Stress, missed meals, bright sunshine and air travel How about the headache itself? Where She had been told that nothing helps once the have precipitated attacks. do you feel the pain and how long does attack begins and prevention is the best approach. the attack last? Do you have any other She takes over-the-counter naproxen but to little symptoms with the headache? Do you effect. Vomiting no longer gives relief. Hot com- PRETEST ever have numbness, tingling or other presses, warm showers help. During the attack, she 1) What is the diagnosis? unusual sensations during or before the becomes irritable and angry and avoids contact with 2) Does this patient require imaging? If yes, which attack? others, taking the phone off the hook. studies and why? The headache is frontal behind the eyes, mainly on 3) What features help to determine the diagnosis? the right, and spreads to include the back of the You mention feeling irritable and angry a)Duration of visual symptoms. head. These severe headaches last about 2 days. during your attacks. Have you had any b)Unilateral location of visual and pain Then the pain fades and she feels “bad” for another other problems with your mood? symptoms. 24 hours before she can return to work. The Her headaches make her very depressed and the c) Duration of attack. headache is accompanied by nausea and vomiting. aura makes her feel panicky, especially if at work. d)Timing of visual symptoms and headache. She cannot tolerate light or loud noise; perfumes She also has bouts of depression unrelated to her e) Paresthesias. and cooking aromas aggravate the headache. headaches – worse during winter. She saw a psychi- f) Lack of response to propranolol. Occasionally she has diarrhea with the attack. atrist and was treated with sertraline (Zoloft). She g)Light/sound sensitivity. During the attack she notices her left hand and fore- noticed no improvement in mood but could not h)Intolerance to odors (osmophobia). arm develop “pins-and-needles” sensations. continue therapy because of insurance problems. i) Positive family history. j) Vomiting associated with headache. Does anyone else in your family have k)Diarrhea associated with headache. headaches or depression or other mood 4) What are the goals of therapy for this patient? problems? chologist for supportive therapy if indicated. Choice COMMENTARY of propranolol as preventive therapy is questionable, Theresa has migraine with aura (formerly known as given her depression and low frequency of attacks. “classic migraine”). She will be referred for a Editor However, given that Theresa also reports feeling anx- psychiatric consultation for evaluation and Carol Hart, PhD ious at the onset of her aura, the propranolol should diagnosis of comorbid depression/anxiety. be discontinued by tapering the doses since it also has anxiolytic effects. Amitriptyline may be consid- Editorial Board Tell me about the vision problems, ered after review with the consulting psychiatrist. J. Keith Campbell, MD Theresa. What happens to your vision R. Michael Gallagher, DO and how long does the problem last? Does anyone else in your family have Robert Smith, MD Theresa describes a typical migraine aura consisting headaches or depression or other mood of visual disturbances largely confined to one visual problems? AASH Board of Directors field. While she experiences some continued blurring A positive family history is common for both President of vision, the aura itself lasts less than one hour, migraine and mood disorders; comorbidity occurs James R. Couch, MD, PhD meeting the International Headache Society (IHS) more frequently than by chance, as shown in a President-Elect diagnostic criteria for migraine with typical aura. number of epidemiological studies. Richard B. Lipton, MD Treasurer How about the headache itself? Where do You are worried about your job, and you Paul Winner, DO you feel the pain and how long does the also feel depressed at times. Is your Secretary attack last? Do you have any other social or family life affected? Are you Robert B. Daroff, MD symptoms with the headache? Do you able to enjoy yourself? Immediate Past President ever have numbness, tingling or other Her active life and positive attitude suggest that her J. Keith Campbell, MD unusual sensations during or before the quality of life is not significantly impaired by either Members-at-Large attack? the depression or the migraines. She might respond Harvey J. Blumenthal, MD The location and duration of the headache are well to nonpharmacologic management, such as Steven B. Graff-Radford, DDS compatible with a diagnosis of migraine. Her biofeedback and relaxation therapy. Alvin E. Lake, III, PhD nausea/vomiting and light and sound sensitivity are Elizabeth W. Loder, MD also diagnostic. Strong odors are known to trigger Aside from these severe headaches, do John F. Rothrock, MD and/or exacerbate attacks in some migraineurs. In you have other headaches that also need Thomas N. Ward, MD migraine with aura, sensory disturbances, such as attention? the unilateral paresthesia she describes, often follow It is not uncommon for depressed migraineurs to Executive Director the visual disturbances. Fatigue or weakness can have frequent tension-type headaches that last days Linda McGillicuddy occur in the postdrome or final phase of the attack; to weeks. Unless this question is asked, the clinician however, Theresa’s comment about feeling so “bad” may fail to diagnose and treat these less severe but AASH Headache Profiles is published by after the migraine that she misses work suggests the persistent headaches. the American Association for the Study of need for further questioning about depression. Does anything seem to trigger your Headache, with business offices located at 19 How often do you get these headaches? severe headaches? Mantua Road, Mt. Royal, NJ 08061. Our world Has their severity or frequency changed? These are all common migraine triggers; they are wide web address is http://www.aash.org. Even when the diagnosis seems clear and the also largely preventable or avoidable. One can men- Letters to the editor should be sent to the above headache condition is long-standing, it’s vital to tion some simple prevention strategies, such as address, or emailed to [email protected] determine if there has been a change in the wearing sunglasses outdoors on bright days to avoid Copyright 1999 by the American Association for headache pattern that might suggest the emergence the visual stimulation. For air travel, one can sug- the Study of Headache. of secondary headache due to underlying pathology. gest packing snacks, water and pain relievers in a Her concern about losing her new job provides an carry-on. Some basic instructions on deep breathing answer to a related issue: “Why is this patient with a for stress reduction might also be worthwhile. AASH Special Membership Offer long-standing complaint here today? What has Theresa’s response to these suggestions will help in First-year dues are only $99 changed?” deciding whether she is a good candidate for behav- ioral approaches versus pharmacologic prophylaxis.