Severe Headache in a Patient With Migraines

Case Study

A rapid response event was initiated by the bedside nurse for a patient because of a severe headache and multiple episodes of vomiting. The patient paged her nurse to inform her that she had an intense, pounding right-sided headache for the past 2 h and that the lights were making her headache worse. The patient had an episode of vomiting just before her nurse arrived. Upon prompt arrival of the rapid response team, the nurse informed that the patient was a 42-year-old female with a history of hypothyroidism; she was post-operative day zero after laparoscopic cholecystectomy.

Vital Signs

Temperature: 98.2 °F, axillary
Blood Pressure: 138/68 mmHg
Heart Rate: 87 beats per min (bpm) – normal sinus rhythm on telemetry
Respiratory Rate: 14 breaths per min
Pulse Oximetry: 99% saturation on room air

Focused Physical Examination

A quick exam revealed a middle-aged female sitting in bed with a pair of sunglasses on. She was in moderate distress secondary to pain. The patient’s cranial nerve testing did not demonstrate any abnormalities, but the penlight used for the exam worsened her distress. She did not have any temple tenderness. She was alert and orientated. She demonstrated full strength of all extremities. Heel-shin testing was within normal limits. Her cardiac and pulmonary exams were benign. Her abdominal exam revealed several clean, dry, and intact bandages. Bowel sounds were present in all four quadrants. She denied any numbness, tingling, double vision, and blurry vision. She endorsed some mild abdominal discomfort from her recent surgery. The patient reported that she has a history of occasionally getting migraines that would require her to come to the emergency room for treatment. She stated that her current headache felt similar to her previous migraine episodes.

Interventions

Since there were no focal neurological deficits on the physical exam, vital signs were stable, and the headache was similar in presentation to her previous migraines, it was determined that the patient was experiencing her typical migraine. No emergent imaging or labs were obtained. She was given a 1 L bolus of lactated ringers, ketorolac 30 mg IV, ondansetron 4 mg IV, and diphenhydramine 25 mg IV. Then, 2 h later, the patient’s nurse contacted the intern on the rapid response team to let her know that the patient’s headache had completely resolved.

Final Diagnosis

Severe headache because of intractable migraine.

Migraine

Despite being one of the top five most prevalent diseases globally and accounting for over one million visits to emergency rooms in the United States each year, the pathogenesis behind migraines remains a mystery. Although initially thought to be related to vasodilation and vasoconstriction of cerebral blood vessels, current research points toward the trigeminal nerve and its surrounding vasculature being influenced by inflammatory compounds may be the true source of migraines. There tends to be a strong familial component to migraines. However, despite the current advances in genomics, no specific gene(s) have been identified that predispose individuals to migraines.

Migraine is typically described as a unilateral headache that tends to be pounding or pulsatile. The headache can last from hours to several days and is usually associated with nausea and/or vomiting. Photophobia and phonophobia are also commonly associated symptoms. Some migraine sufferers will also have a preceding aura, which can either be visual, sensory, or less commonly motor. Common visual auras include blurry vision, partial vision loss, or even complete vision loss. Unilateral extremity or facial numbness/tingling are seen with sensory auras. Motor auras, the rarest form of migraine auras, can manifest with extremity or facial weakness.

It can occasionally be challenging to distinguish migraine from other forms of headaches, especially in the setting of a rapid response called for severe headache, despite the distinct characteristics of each type of headache. It is important that characteristics of other types and etiologies of headaches be kept in mind. Table 48.1 presents a brief comparison of various types of headaches.

Table 48.1

Common types of headaches

	Migraine	Cluster	Sinus	Tension
Characteristics	Unilateral, pounding, or pulsatile, associated with nausea/vomiting	Severe pain around the eye with eye tearing, runny nose, eye redness, or drooping eyelid	Forehead pain, runny nose/congestion, ear pain	Dull, pressure across the forehead, “band-like pain,” most common type of headache
Acute Treatment	IV fluids, non-steroidal anti-inflammatory drugs (NSAIDs), anti-emetic, diphenhydramine	High flow oxygen (12-15 L/min via non-rebreather), triptan therapy	Decongestants, nasal sprays	NSAIDs, acetaminophen, caffeine