New Headache Case

[jmj11]

Okay, in summary, here is a lady (which I saw today) who has had a disabling headache disorder for 16 years. She has been seen by about 20 providers, some specialists, a couple of PAs (including the one who sent her to me), yet she has never been diagnoses correctly and all treatments were inadequate. However, I bet you guys can figure this out rather quickly and the sad thing (for her) this should be a very treatable disorder.

 

57 year old lady with a left peri-orbital-temporal headache that is a 10/10 for 16 years. She has considered suicide at times because she has had no help. Many drugs have been thrown at her with no benefit.

 

So ask me some standard headache questions and you can figure this out. Rather than guessing right away, ask headache historical questions to solve the case. I will avoid you wasting time by telling you MRI brain (done last week) CT sinuses, all labs including sed rate . . . all normal. She is otherwise in good health.

 

Go at it!

[alleycat]

with the hx you've given, multiple providers, multiple failed med, all appropriate testing neg, 16 yrs duration...I'm thinking somataform disorder.

 

but, perhaps that's been considered and r/o.

 

so, any triggers for this HA?

any time at all when s/sx are neg?

any fhx of HA??

visual exams all neg??

any concommitant meds for all 16 years??

any hx of TBI or CHI??

[jmj11]

with the hx you've given, multiple providers, multiple failed med, all appropriate testing neg, 16 yrs duration...I'm thinking somataform disorder. - no

 

but, perhaps that's been considered and r/o.

 

so, any triggers for this HA? - ETOH

any time at all when s/sx are neg? - sx not constant if that is what you're asking

any fhx of HA?? - no, absolutely none

visual exams all neg?? - near normal with glasses.

any concommitant meds for all 16 years?? - just things thrown at her headache. She is on three now and I'm stopping all of them.

any hx of TBI or CHI?? - no.

[alleycat]

"...so, any triggers for this HA? - ETOH "

any time at all when s/sx are neg? - sx not constant if that is what you're asking

 

asking, is she ever HA free?? ever??

 

they only appear w/ ETOH?? or also w/o??? and if only w/, why does she drink?? just askin'

[jmj11]

"...so, any triggers for this HA? - ETOH "

any time at all when s/sx are neg? - sx not constant if that is what you're asking

 

asking, is she ever HA free?? ever??

 

they only appear w/ ETOH?? or also w/o??? and if only w/, why does she drink?? just askin'

 

She is headache free . . . hint . . . most of the time she is headache free, otherwise she would have committed suicide.

 

She stopped drinking ETOH 16 years ago when she figured out it would trigger a headache. The vast majority of headaches have no provocation.

[jdenning]

It wouldn't surprise me at all if at least some of her headache is due to medication rebound from all the stuff she's been taking....BTW is she on any hormone replacement???

[jmj11]

It wouldn't surprise me at all if at least some of her headache is due to medication rebound from all the stuff she's been taking....BTW is she on any hormone replacement???

It wasn't from rebound. You didn't know this but for many of the 16 years she gave up and took nothing. She is not on HRT.

 

Some other interesting questions for headache should be time, how fast onset (which I call Tmax) frequency, duration, associated symptoms etc. Just a suggestion.

[jdenning]

So she is headache free most of the time. Does she know they are coming? What does she feel when a headache is coming on? Does she have visual changes? Nausea? Photophobia? How long from beginning of sx to full intensity? Does the pain migrate? Does anything else go along with the headache? Does headache always occur before/during/after certain kinds of activity (like sex for example)?

 

Depending on the answers to some of those questions, I might be thinking a migraine variant, but given the difficulties she's had I might speculate something more complicated than migraine

[donwinder]

Thanks for the question...

 

photophobia,

phonophobia,

n/v, dizziness

visual changes? scintillating scotomata?

Hx of head/neck trauma?

HTN?

Worse with coughing, sneezing?

 

 

DDx so far:

Migraines

Cluster HA

Trigeminal neuralgia

TMJ

Pseudotumor cerebri

[jmj11]

So she is headache free most of the time. Does she know they are coming? no What does she feel when a headache is coming on? just pain Does she have visual changes? no Nausea? no Photophobia? no How long from beginning of sx to full intensity?20 seconds Does the pain migrate? starts just above her left eye, moves around the eye into the temple Does anything else go along with the headache? tearing of her eye Does headache always occur before/during/after certain kinds of activity (like sex for example)? ​no

 

Depending on the answers to some of those questions, I might be thinking a migraine variant, but given the difficulties she's had I might speculate something more complicated than migraine

[jdenning]

Unilateral presentation and tearing make me think cluster.....but somehow I'm thinking there is more to this perhaps?

[alleycat]

does she have any hx of other vascular or neuro findings??

 

I'm thinkin' something along line of aneurysms, neuropathies.

 

how long duration?? (did I miss it?)

 

and frequency??

 

what, literally, does she do while having HA??

[jmj11]

Thanks for the question...

 

photophobia, no

phonophobia, no

n/v, dizziness no

visual changes? scintillating scotomata? no

Hx of head/neck trauma? no

HTN? prehypertension, not related

Worse with coughing, sneezing? no

 

 

DDx so far:

Migraines no

Cluster HA no

Trigeminal neuralgia no

TMJ no

Pseudotumor cerebri no

[EMEDPA]

eeg nl?

time of day when she gets h/a or random(only when the kids get home from school, etc).

[jmj11]

does she have any hx of other vascular or neuro findings?? no

 

I'm thinkin' something along line of aneurysms, neuropathies. nope

 

how long duration?? (did I miss it?) no, great question . . . 10-15 minutes

 

and frequency?? no, another great question . . . 5-15 attacks per day

 

what, literally, does she do while having HA?? another great question, sits leaning over and holding her head, moans and sometimes her husband rubs her neck.

[jmj11]

eeg nl? not done as far as I know

time of day when she gets h/a or random(only when the kids get home from school, etc). seems random, although one or two attacks can happen at night while she is sleeping.

[EMEDPA]

does she ever get a h/a when her husband isn't around to rub her neck?

[jmj11]

does she ever get a h/a when her husband isn't around to rub her neck? Yes. I know that many of mine have been psych, this one is not. She seems very stable and this headache syndrome is the biggest problem of her life.

 

Okay, I'm going to bed. I will leave the summary to "soak" overnight, thinking that one of you whiz kids will figure it out. I will make some key points.

 

Female

Severe headache

Unilateral

Sudden onset

Last only 15 minutes

Comes very frequent, 15 times per day

Can be provoked by ETOH

Not psychogenic

Not Secondary

 

And lastly, one or more rare headache types I see. The last one I saw was over a year ago . . . and headache is all I do.

 

With the above and the Internet I'm sure you will get it. But the treatment is usually easily but sometimes intractible. She's had no good treatments in 16 years.

 

 

[jdenning]

Well, if Mike only sees this rarely, then this one must be a zebra. I'm going to say (only because I found almost this EXACT same discussion on another forum) that our diagnosis is chronic paroxysmal hemicrania and that she should get better with indomethacin.

 

I"m not that smart...I just know a good google.

[alleycat]

just read MedScape's brief on chronic parox hemi. CPH. after reading jdenning,,, sounds like the lady pt.

 

has she ever been tried on indomethacin????

 

did she have a pos response???

 

 

jdenning,,,mind sharing address of "other forum"?? I'm always looking for educ.

[jdenning]

So I googled "female unilateral headache" and found something "aippg.com" - I have no idea what that is - and here was this full page discussion of exactly what we were talking about.

 

I work in a neurology office and am starting to see more and more headache patients. Most of what I see is pretty non complicated though you'd be surprised at the number of people we see who are taking chronic narcotics for something (back pain, knee pain, shoulder pain, whatever) who are completely surprised that their headaches might be caused by their chronic medication use. Just today I had a patient complaining of terrible headaches in the morning. I reviewed her med list and asked her what she takes oxycodone for. She takes 5 (!) oxycodone per day for back pain. Says she probably doesn't need that many but takes them anyway. I asked to try cutting back to see if her headache changes, and if not, to come in. BTW, we were discussing this by phone because she didn't want the expense of an appointment.....

 

The other place I've learned to look is whether female patients complaining of headache are taking HRT. I saw a lady last week who had chronic daily headaches that disappeared as soon as she stopped Estrace.

 

On a different note, Mike, are you doing Botox for migraine?

[jmj11]

Yes, it is CPH. I started her on Indocin yesterday and we will see what happens but I'm confident she will get better.

 

Yeah, I'm doing Botox for migraine.

[d2305]

Seems that someone must have used prednisone or decadron in the past, which would work (?).

[jmj11]

Seems that someone must have used prednisone or decadron in the past, which would work (?).

 

Honestly I'm not sure. I only see a case once a year or so. It is a chronic condition so that steroids aren't a good long term solution. In cluster it has its place to knock down a cycle but not for maintenance. I've always used Indocin or Verapamil.

[rcdavis]

Mike , you had a case like this last year. Almost same presentation. once again; nice job. too bad the insurance company cant see this. or appreciate it.