migraine
Doctor Information
Leanne Ainscough, age 31
PMH
Eczema
Hayfever
Medication
Zerobase 11% cream
Cetirizine 10mg daily prn
Microgynon 30
Allergic to penicillin
PMH
Eczema
Hayfever
Medication
Zerobase 11% cream
Cetirizine 10mg daily prn
Microgynon 30
Allergic to penicillin
Patient Information
Leanne Ainscough, age 31
History: You have a headache that started yesterday. It is pounding all over your head, but mostly on the right side. You called in sick from work and your manager told you to get to the doctor. The headache is really bad, it just started building up yesterday morning, and by the end of the day you felt sick and just needed to lie down. Work were good and let you go early, and you hoped that a good nights sleep would get rid of it.
If asked only - you have had a headache like this once or twice before - maybe a year ago. You cannot think of anything that triggered this one on. You have been nauseous but not vomited. You have a little bit of light sensitivity but to be honest you have been asleep for most of the last 24 hours anyway. No other visual disturbance, no symptoms in your arms or legs, and the headache does not change with position. You did not have any preceeding symptoms nor a warning that this headache was about to come on.
You work in an office, sitting at the computer, but you have done this job for 6 years. You enjoy it and are not stressed at work. You live with your best friend Karla in a studio apartment, and you have recently started seeing someone that you knew from uni. You smoke 2 cigarettes per day (this is pretty good since you used to smoke 10), and you don’t bother with alcohol. You have eczema and hayfever, both of which are under control, but you have treatment at home if you need it You have also taken the combined pill since you were about 25.
Your mum and dad live locally, and your remember your mum getting headaches at the weekends quite a lot when you were small. This time you took two paracetamol extra strong, hasn't really made a difference.
Ideas: this is probably a migraine, but you are surprised it has lasted so long
Concerns: you don't fancy getting any more of these, can you take a stronger painkiller?
Expectation: to be told it is a migraine and given some strong painkillers
Once the doctor has examined you, they should explain what a migraine is and typical symptoms. You do not wish to take a tablet every day, and don’t really feel you need to. You will agree to taking simple painkillers if it happens again or anti-migraine tablets (e.g. sumatriptan), and to keeping a diary of events. If the doctor mentions stopping your pill due to the DVT risk, you question this because you have been on the pill for years so surely it wouldn't make any difference now? You will push to stay on it because it does the job and you have heard all sorts of things about the other methods. If the doctor is nice and empathetic and explains the risk you will agree to come off the combined pill, and take a leaflet to look into other options and come back in to discuss it at a later date.
History: You have a headache that started yesterday. It is pounding all over your head, but mostly on the right side. You called in sick from work and your manager told you to get to the doctor. The headache is really bad, it just started building up yesterday morning, and by the end of the day you felt sick and just needed to lie down. Work were good and let you go early, and you hoped that a good nights sleep would get rid of it.
If asked only - you have had a headache like this once or twice before - maybe a year ago. You cannot think of anything that triggered this one on. You have been nauseous but not vomited. You have a little bit of light sensitivity but to be honest you have been asleep for most of the last 24 hours anyway. No other visual disturbance, no symptoms in your arms or legs, and the headache does not change with position. You did not have any preceeding symptoms nor a warning that this headache was about to come on.
You work in an office, sitting at the computer, but you have done this job for 6 years. You enjoy it and are not stressed at work. You live with your best friend Karla in a studio apartment, and you have recently started seeing someone that you knew from uni. You smoke 2 cigarettes per day (this is pretty good since you used to smoke 10), and you don’t bother with alcohol. You have eczema and hayfever, both of which are under control, but you have treatment at home if you need it You have also taken the combined pill since you were about 25.
Your mum and dad live locally, and your remember your mum getting headaches at the weekends quite a lot when you were small. This time you took two paracetamol extra strong, hasn't really made a difference.
Ideas: this is probably a migraine, but you are surprised it has lasted so long
Concerns: you don't fancy getting any more of these, can you take a stronger painkiller?
Expectation: to be told it is a migraine and given some strong painkillers
Once the doctor has examined you, they should explain what a migraine is and typical symptoms. You do not wish to take a tablet every day, and don’t really feel you need to. You will agree to taking simple painkillers if it happens again or anti-migraine tablets (e.g. sumatriptan), and to keeping a diary of events. If the doctor mentions stopping your pill due to the DVT risk, you question this because you have been on the pill for years so surely it wouldn't make any difference now? You will push to stay on it because it does the job and you have heard all sorts of things about the other methods. If the doctor is nice and empathetic and explains the risk you will agree to come off the combined pill, and take a leaflet to look into other options and come back in to discuss it at a later date.
Examination Findings
Pulse 77
Blood pressure 121/74
Pupils equal and reactive, mild photophobia
Fundi - no papilloedema
Cranial examination normal
Peripheral examination normal
Blood pressure 121/74
Pupils equal and reactive, mild photophobia
Fundi - no papilloedema
Cranial examination normal
Peripheral examination normal
Mark scheme
Data Gathering
|
POSITIVE INDICATORS
Organised and systematic in gathering information from history taking, examination and investigation Identifies abnormal findings or results and/or recognises their implications Data gathering does appears to be guided by the probabilities of disease Undertakes physical examination competently, or use instruments proficiently Uses an incremental approach using time and accepting uncertainty |
NEGATIVE INDICATORS
Makes immediate assumptions about the problem Intervenes rather than using appropriate expectant management Is disorganised/unsystematic in gathering information Data gathering does not appear to be guided by the probabilities of disease. Fails to identify abnormal data or correctly interpret them |
Clinical Management Skills
|
POSITIVE INDICATORS
Makes appropriate diagnosis Develops a management plan (including prescribing) that is appropriate and in line with current best practice Makes plans that reflect the natural history of common problems Management approaches reflect an appropriate assessment of risk Makes appropriate prescribing decisions Manages risk effectively, safety netting appropriately Simultaneously manages multiple health problems, both the migraine and the contraception Encourages the patient to participate in appropriate health promotion and disease prevention strategies - to stop the pill Follow-up arrangements and safety netting are adequate |
NEGATIVE INDICATORS
Fails to consider common conditions in the differential diagnosis Does not suggest how the problem might develop or resolve Fails to make the patient aware of relative risks of different approaches Decisions on whether/what to prescribe are inappropriate or idiosyncratic. Refers onwards Follow-up arrangements are absent or disjointed unable to construct a problem list and prioritise Unable to enhance patient’s health perceptions and coping strategies |
Inter Personal Skills
|
POSITIVE INDICATORS
Identify patient’s agenda, health beliefs & preferences / does makes use of verbal & non-verbal cues. Works with the patient to develop a shared management plan or clarify the roles of doctor and patient Uses explanations that are relevant and understandable to the patient Shows sensitivity for the patient’s feelings in all aspects of the consultation including physical examination Does not allow own views/values to inappropriately influence dialogue |
NEGATIVE INDICATORS
Doesn't enquire about patients ICE Takes a doctor centered approach towards management Uses an explanation that is filled with jargon, or forgets to explain at all Doesn't show any sympathy / empathy towards the patient's situation Fails to empower patient |
Management
Explanation: Migraine is a type of headache that is quite common. The exact cause is not know, but it is thought to be due to blood vessels inside the head becoming narrower. Some people get them once in a while, others get them often. Some people get a warning sign before the headache, called an aura. This can be anything from a strange feeling, to flashing lights in their vision, to an unusual smell. The headache itself can come with sickness/tiredness and difficulty looking at light. It can last several hours. Depending on the type of migraine you have, there are various treatments available.
The history of symptoms is the most reliable way to diagnose a migraine. In addition to the typical unilateral pulsating headache that is made worse by physical activity, look for sickness, photophobia, and sensory symptoms in the arms or legs. You still need to exclude the headache red flags: fever, sudden onset, following trauma, suggestion of raised intracranial pressure, progressive symptoms; these patients require urgent specialist assessment. Think also about possible trigger (the usual suspects are cheese, chocolate, red wine, stress), the effect on quality of life, and any family history.
For some patients, it may be useful for them to do a headache diary, assessing the frequency, nature and any triggers, particularly if the diagnosis is uncertain. In this case the other thing to be wary off is women on combined hormone contraception - it is not only a risk for for increased severity of migraine, but migraine with aura is a contraindication to taking it. This patient needs to be counselled about suitable alternatives.
The next thing to think about is acute treatments versus preventative treatment. In someone that has frequent migraines, perhaps prophylaxis is more appropriate, compared to someone that has one every couple of months. Simple things first - paracetamol/ibuprofen are often good to use for an acute headache, as well as oral sumatriptan 50 or 100mg. Other ‘triptans’ are available but are generally pricy and should be used second line. High dose aspirin (900mg) can also be used, although many are reluctant to use this. If sickness is a big problem, short term metoclopramide or domperidone can be considered. There is an argument for these even if nausea or vomiting is not present.
Preventative medication should be considered if there are 2 attacks or more per month, or acute medication is not tolerated. It can also be used where the patient is at risk of medication overuse headache. The two first line treatments are topiramate (25mg on titrated up weekly as tolerated) or propranolol (80mg od or bd). Women of childbearing age should be aware that topiramate can increase the risk of feral abnormalities. If these fail, there is gabapentin or acupuncture, the latter of which is becoming increasingly popular.
Regarding the CHC (combined hormonal contraceptive) and migraines, there are lots of guidelines around what you should and shouldn't do. This case is a little difficult, as you should advise her to stop using the CHC. As per the FRSH guidelines, a migraine with aura is a UKMEC 4 - absolute contraindication. A migraine without aura, is a UKMEC 2 or 3 depending on whether you are initiating or continuing the CHC. In this case as you are continuing with the use of CHC, it is classified as UKMEC 3 - so the risks outweigh the advantages.
The history of symptoms is the most reliable way to diagnose a migraine. In addition to the typical unilateral pulsating headache that is made worse by physical activity, look for sickness, photophobia, and sensory symptoms in the arms or legs. You still need to exclude the headache red flags: fever, sudden onset, following trauma, suggestion of raised intracranial pressure, progressive symptoms; these patients require urgent specialist assessment. Think also about possible trigger (the usual suspects are cheese, chocolate, red wine, stress), the effect on quality of life, and any family history.
For some patients, it may be useful for them to do a headache diary, assessing the frequency, nature and any triggers, particularly if the diagnosis is uncertain. In this case the other thing to be wary off is women on combined hormone contraception - it is not only a risk for for increased severity of migraine, but migraine with aura is a contraindication to taking it. This patient needs to be counselled about suitable alternatives.
The next thing to think about is acute treatments versus preventative treatment. In someone that has frequent migraines, perhaps prophylaxis is more appropriate, compared to someone that has one every couple of months. Simple things first - paracetamol/ibuprofen are often good to use for an acute headache, as well as oral sumatriptan 50 or 100mg. Other ‘triptans’ are available but are generally pricy and should be used second line. High dose aspirin (900mg) can also be used, although many are reluctant to use this. If sickness is a big problem, short term metoclopramide or domperidone can be considered. There is an argument for these even if nausea or vomiting is not present.
Preventative medication should be considered if there are 2 attacks or more per month, or acute medication is not tolerated. It can also be used where the patient is at risk of medication overuse headache. The two first line treatments are topiramate (25mg on titrated up weekly as tolerated) or propranolol (80mg od or bd). Women of childbearing age should be aware that topiramate can increase the risk of feral abnormalities. If these fail, there is gabapentin or acupuncture, the latter of which is becoming increasingly popular.
Regarding the CHC (combined hormonal contraceptive) and migraines, there are lots of guidelines around what you should and shouldn't do. This case is a little difficult, as you should advise her to stop using the CHC. As per the FRSH guidelines, a migraine with aura is a UKMEC 4 - absolute contraindication. A migraine without aura, is a UKMEC 2 or 3 depending on whether you are initiating or continuing the CHC. In this case as you are continuing with the use of CHC, it is classified as UKMEC 3 - so the risks outweigh the advantages.