1. A 25-year-old man is seen in clinic with a 3 year history of headaches. He had been headache free for the last 2 years but they have recurred once again and typically occur at night and awaken him from his sleep within the first hour of sleep. The headaches are described at being sharp right retroorbital pain (10/10 in intensity) and he becomes teary-eyed during this time. They have been occurring every night for the last 5 weeks and he has had no relief with NSAIDs or tylenol. There is no family history of headaches. The only recent trigger that he thinks may have caused these episodes was heavy alcohol intake about 5 weeks ago.

What is the most likely diagnosis?

A. migraines without aura
B. tension headaches
C. cluster headaches
D. obstructive sleep apnea

2. A 44-year-old woman is seen in the clinic for evaluations of migraines. She has had migraine attacks for several years where the main triggers tend to be loud noises. There is also a strong family history of migraines and at present she is not on any prophylactic therapy. The migraines usually last for 24 hours, getting minimal relief with analgesic therapy and her postdromal phase is relatively brief. She had a migraine 2 weeks ago with an aura (visual: scotomas)  lasting for about 1 hour with profound nausea but no vomiting. The migraine itself lasted for about 4 days and she was briefly hospitalized for intravenous medications with dihydroergotamine as part of the Raskin protocol. She has no other significant medical history.  She is seen in clinic with normal vitals and a normal neurological exam.

What is the most reasonable next step in the management of this patient? 

A. start amitriptyline at 40 mg QHS
B. start propanolol 15 mg QID
C. start topiramate 50 mg BID
D. start valproic acid 250 mg BID
E. all of the above

ANSWERS

1. C– this patient has a diagnosis in keeping with cluster headaches. It is occurs in about 0.1% of the population and is a rarer form of primary headaches. It is typically nocturnal and retroorbital in nature affecting mostly young males associated with severe pain and sometimes unilateral lacrimation. His clinical history of having similar headaches and being symptom-free for a long period of time is classically described in cluster headaches.  Alcohol can provoke episodes in many patients with cluster headaches. Acute attacks are usually managed with high flow oxygen for about 20 minutes.  Prophylaxis can be instituted with verapamil or lithium.

2. E – This patient would benefit from prophylactic therapy with any of the medications listed given that she has had episodic migraines with prolonged auras.  She had been admitted with status migrainosus (migraine > 72 hours). Apart from lifestyle recommendations such as regular sleep, reduction in dietary caffeine intake, limiting artificial sweeteners and avoidance of known triggers, the following medications have the best evidence for the prevention of episodic migraines : propanolol, amitriptyline, topiramate, valproic acid, & timolol.   A history of renal stones or significant renal dysfunction is a relative contraindication for the use of topiramate. Indications for pharmacological prophylaxis include but are not limited to: auras lasting >1 hour; complex auras (hemiplegia, stroke-like symptoms); >2 migraines per week; headaches remain despite acute intervention. Read more about migraines here on Medscape.