MEDizzy - A 39-year-old female presents to your office with a 3-year

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Medicine test

A 39-year-old female presents to your office with a 3-year history of headaches. They occur once or twice per week, lasting several hours. The headaches are throbbing and are usually on her left side. During these episodes, the patient is incapacitated and must lie down in a dark room for several hours. She is sensitive to light during the episodes and cannot move because of the pain. She is often nauseated and has vomited on several occasions. Medical history is significant for hypothyroidism, for which she takes levothyroxine (Synthroid). Her physical examination is unremarkable, however the patient endorses another similar headache and begins vomiting near the end of the examination. What is the appropriate next step in managing this patient?

Explanation. Chlorpromazine. The patient in this question is likely having an acute episode of a migraine headache. Migraines are characterized by unilateral, pulsating pain that is often associated with photophobia and an aura of neurologic symptoms prior to the onset of the headache. Acute attacks can range in duration from 4 to 72 hours. Acute treatment and primary preventive treatment vary in migraine headaches. Acute attacks are best treated with intravenous antiemetic medications (chlorpromazine and prochlorperazine) and/or triptans (sumatriptan). (E) Given that this patient presents with vomiting, chlorpromazine is the best choice since it can be given in IV form, unlike sumatriptan. (A, B) Propranolol and amitriptyline are both excellent medications used for migraine prophylaxis, not for acute episodes. These would be appropriate to give to the patient after her acute migraine episode resolves to prevent further attacks. (D) Verapamil is a calcium channel blocker that is the first-line medication for cluster headache prophylaxis. However, this patient is having a migraine, not a cluster headache. Cluster headaches typically involve pain around the eye with eye watering, nasal congestion, and swelling.