A 28-year-old man is evaluated for a 5-year history of recurrent headache that occurs several times per month and lasts 12 to 24 hours. He describes the headache as a bilateral frontal pressure associated with nasal congestion and sensitivity to light, sound, and smell. The pain is generally moderate in intensity but worsens when he bends forward or exercises and has caused him to miss 3 days of work recently. He has no nausea or visual or neurologic symptoms. The patient has a history of nonseasonal allergic rhinitis treated with pseudoephedrine and loratadine and a family history of headaches in his paternal grandmother. His only other medication is naproxen, which he takes as needed for the headache pain but has become less effective over time.
Physical examination findings, including vital signs and results of neurologic examination, are normal.
Which of the following is the most appropriate management of this patient’s disorder?
A: CT scan of the sinuses
B: MRI of the brain
C: Nasal corticosteroids
MKSAP Answer and Critique
The correct answer is E: Sumatriptan.
This patient should be treated with sumatriptan. He reports episodes of moderate to severe headache that meet the diagnostic criteria for migraine. Migraine without aura can be diagnosed if the following diagnostic criteria are fulfilled:
1) Headache lasting 4 to 72 hours
2) Headache with at least two of the following characteristics:
- Is unilateral
- Is pulsatile
- Is of moderate or severe intensity
- Is aggravated by routine physical activity
3) Headache accompanied by at least one of the following associated symptoms:
- Nausea and/or vomiting
- Photophobia and/or phonophobia
4) At least five headache attacks that fulfill these criteria
5) History and findings from physical and neurologic examinations not suggestive of any underlying organic disease
This patient’s attacks have recurred for 5 years, fit the 4- to 72-hour duration of migraine, and possess two of the four pain-feature requirements (moderate intensity and aggravation by routine activity) and one of the two associated feature requirements (photophobia and phonophobia). In the absence of contraindications, the use of triptans, such as sumatriptan, is an appropriate treatment for a migraine that does not respond to NSAIDs.
Given that the patient’s headache meets the criteria for migraine and that no findings suggest an alternative diagnosis, neither CT of the patient’s sinuses nor treatment with nasal corticosteroids is indicated.
An MRI of the brain or any other neuroimaging study is unnecessary in this patient in the presence of a stable 5-year pattern of episodic headaches that meet criteria for migraine, normal findings on neurologic examination, and the absence of any red flags of secondary headache.
Evidence-based guidelines do not support the use of oxycodone or other opioids in the treatment of acute migraine except when NSAIDs or triptans fail or are contraindicated.
- In the absence of contraindications, the use of triptans, such as sumatriptan, is an appropriate treatment for a migraine that does not respond to NSAIDs.
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