Patient Case Study: Migraine
Assignment Content
Karen Myers a 35-year old, who was recently promoted to CEO of a marketing company, presents to the FNP for c/o increasing migraines. She does not have a migraine today but has a past medical history (PMH) of migraines since her early 20s and was able to manage them effectively with OTC Excedrin® Migraine, however, it is no longer effective. Her job requires her to be “at the top of her game,” and she expresses frustration since she has missed work a few times over the past month due to the migraines when she had to retreat to her dark, quiet bedroom and try to sleep it off. She describes a scintillating scotoma aura she has always experienced with her migraines. The evolution of her migraines has not changed, and she describes it as always unilateral, starting in her occipital scalp and migrating retro-orbitally.
ROS: GI: c/o mild nausea with migraines but has never vomited, Neuro: See HPI; Denies red flags. — PMH: Migraines — Meds: Excedrin Migraine prn — Allergies: NKDA — VS: 124/74, P 72, R 16 — BMI 24
Question 1Which of the following is most appropriate to prescribe first line for Karen?
Tramadol 50 mg tab, sig: 2 tabs at the onset of her migraine and repeat every 4 hours until migraine resolved
Propranolol hydrochloride LA 80 mg cap, sig: 1 cap daily
Rizatriptan 5-10 mg tab, sig: 1 tab at onset of migraine; may repeat dose every 2 hours x2
Magnesium 400 mg tab, sig: 1 tab daily
Question 2
The mechanism of action of serotonin receptor agonists is:
Vasodilation by inhibiting the release of vasoactive peptides and blocking pain pathways in the brainstem, thereby inhibiting dural nociception.
Inhibition of prostaglandin synthesis and have a central analgesic mechanism of action
Modulation of neurotransmitters and appears to affect the central serotonin receptor function
Inhibition of vasospasm of the cerebral arteries and preventing cerebral hypoxia during migraine attacks
Question 3
In a follow-up 3 weeks later, Karen reports success with using the triptan prescribed. She expressed concern over side effects she experienced shortly after taking a dose. Which of the following concerns you the most?
Warming sensation
Drowsiness
Chest tightness
Transient visual loss
Question 4
Which of the following is an unlikely risk factor contributing to Karen’s increased migraine frequency?
Work stress
Jet lag
Dark chocolate and aspartame
Acupuncture
Question 5
You determine Karen is overusing her abortive migraine treatment and want to initiate a prophylactic medication (in addition to abortive treatment). Which of the following medications is most favorable considering the concerns she verbalized above?
Topiramate
Verapamil
Amitriptyline
Candesartan
Botulinum toxin
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Karen Myers a 35-year old, who was recently promoted to CEO of a marketing company, presents to the FNP for c/o increasing migraines. She does not have a migraine today but has a past medical history (PMH) of migraines since her early 20s and was able to manage them effectively with OTC Excedrin
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