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Headache Case #12-478-321


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Okay, I like these interesting case presentations. Mine, unfortunately, are not as sexy as ED and the hospitalists' cases. But I thought I would present one since I know all of her studies and etc. This is a patient I saw yesterday.

 

CC: Headache

 

HPI: A 12 year old female was attending a highschool football game with her sister. During the game she felt a slow onset of a global headache. It reached an intensity of 8/10 so she went home. She had never had a headache before that she could remember. The next day she awaken with a worse headache nausea and vomiting. Her neck hurt. She had no fever. She was taken to the ED. There she had a CBC (normal) and chemistry (all normal but I don't have the tests in front of me). She had a CT. She was afebrile and her vs were normal. She had a CT scan that was normal. She has an LP that was normal. The headache may have lessened slightly (now between a 6-9/10) and the vomiting stopped, but the headache has otherwise continued unchanged for . . . three years (still there yesterday) .

 

ROS: Nothing else.

 

PMHx: Sports related knee injury, nothing else.

 

Social Hx: She seems to come from a good family, no pyscho-social issues that are apparent. The girl was an honor student (and still is but has to do homeschooling now). She was a competitive jazz dancer and the start of her middle school volley ball team. She played for two years with the headache, but it because unbearable and this year, her sophomore year, she didn't go to school or play volleyball or do any dance.

 

Family Hx: Her parents are professionals. She has one older sister. No one in the family have had any type of headaches except that her mother had about two months of episodic migraine with aura when she was in her twenties (a total of about six headaches) and first went on OCCs.

 

Okay, I know a lot more but I will stop here. Any questions?

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ADDITIONAL TESTS: Three MRIs all normal. Another LP with opening and closing pressures normal. More recent labs, including spinal fluids all normal.

 

TREATMENTS: A variety of pain meds were tried, but they never helped that much so she stopped taking them all. Her first neurologist treated her with DHE-45 infusions, sumatriptan, rizatriptan, eletriptan with no benefit. She was placed on nortriptyline, topiramate, verapamil with no benefit. She is presently on propranolol with no benefit. She has had massage, tried magnesium, butterbur and riboflavin with no benefit. She has seen two psychologists and has been dx with a general anxiety disorder, that seems to have come on after entering this period of constant moderate-severe pain. She did do biofeedback. None of these things have helped.

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NDPH? seems to fit the criteria I have read.

 

It is NDPH! Notorious for being poorly understood and very difficult to treat. I have many such patients. I wanted to post a great article about it, but I'm traveling out of state and can't get into those files. I will be back by Wed to post.

 

I think the fact that these headaches started about the time she was in menarche is significant but once again, is poorly understood.

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