10 Migraine Case Studies for Neurologists

  10 Migraine Case Studies for Neurologists

                                                      Case 1:

• Patient: Female, 32 years old, accountant.
• Anamnesis: For 10 years, she has suffered from attacks of intense, throbbing headaches, localized primarily in the right temporal region. The pain lasts from 10 to 24 hours and is accompanied by nausea and increased sensitivity to light (photophobia) and sounds (phonophobia). Attacks occur 2-3 times a month, often associated with the menstrual cycle and work stress. She takes ibuprofen for relief, but it doesn't always help. Her neurological status outside of attacks is normal.
• Task:
  1. Formulate a diagnosis according to the ICHD-3 (International Classification of Headache Disorders) criteria.
  2. Suggest a plan to stop the attack (first- and second-line drugs).
  3. Assess the need and suggest options for preventive therapy.
  4. Provide recommendations for lifestyle changes and keeping a headache diary.

                           
Case 2: Patient: Male, 45 years old, programmer.

• Anamnesis: Complaints of attacks that begin with visual disturbances: a bright, flickering, zigzag line (scintillation scotoma) appears in the left half of the visual field, gradually widening over 20 minutes. After the visual symptoms completely disappear, a severe, bursting headache develops in the occipital region, accompanied by nausea. The patient notes that the headache is less severe than the visual symptoms.
• Task:
  1. Make a diagnosis.
  2. Conduct differential diagnosis with transient ischemic attack (TIA) in the vertebrobasilar system.
  3. Explain to the patient the pathophysiology of aura (the phenomenon of spreading cortical depression).
  4. What are the specifics of prescribing medications for relief (eg, triptans) for migraine with aura?

                  Case 3:
Patient: Woman, 48 years old, unemployed.

• Anamnesis: Headaches have been bothering her almost daily for the past year (more than 20 days a month). The pain is of a pressing nature and moderate intensity, but 8-10 days a month it intensifies to severe levels, acquiring migraine-like features (throbbing, nausea, photophobia). To relieve the pain, the patient takes combination analgesics with caffeine almost daily.
• Task:
  1. Formulate a preliminary diagnosis. What additional diagnosis should be suspected?
  2. Confirm the diagnosis of chronic migraine based on ICHD-3 criteria.
  3. Develop a treatment plan that includes detoxification (withdrawal from abused analgesics).
  4. Offer preventive therapy options approved for chronic migraine (eg, botulinum toxin, monoclonal antibodies).

                                         Case 4:
Patient: A 16-year-old teenager was taken to the emergency room.

• Anamnesis: Half an hour ago, while playing soccer, I suddenly felt weakness in my left arm and leg, numbness on the left side of my face, and difficulty speaking. After 15 minutes, the symptoms regressed, but a severe throbbing headache with vomiting developed. My mother's family history included "strange migraines with weakness." Examination revealed mild left-sided hemiparesis.
• Task:
  1. What should you do in the emergency room? Develop an emergency diagnostic plan to rule out stroke.
  2. Conduct a differential diagnosis.
  3. What type of migraine is most likely? What are the absolute contraindications for treating this type of migraine?
  4. What are the tactics for further family management and counseling?

                           Case 5:
Patient: Woman, 40 years old, marketer.

• Anamnesis: Complaints of spontaneous, recurring episodes of vertigo (a sensation of spinning objects) lasting from 30 minutes to several hours. The dizziness is accompanied by nausea, imbalance, and intolerance to head movements. Headache during these episodes is moderate or absent, but there is a history of typical migraine attacks without aura.
• Task:
  1. Make a diagnosis based on diagnostic criteria.
  2. Conduct differential diagnosis with Meniere's disease, BPPV (benign paroxysmal positional vertigo) and vestibular neuronitis.
  3. Suggest a treatment plan to relieve an attack and for prevention.
  4. What recommendations for vestibular rehabilitation can be given?

                        Case 6:
Patient: Girl, 22 years old, student.

• Anamnesis: Attacks begin with dizziness, tinnitus, slurred speech (dysarthria), double vision, and bilateral numbness in the hands. These symptoms last about 40 minutes and are followed by an intense, throbbing headache in the occipital region, accompanied by vomiting.
• Task:
  1. Formulate a diagnosis.
  2. Conduct a differential diagnosis with vertebrobasilar system pathology. What neuroimaging methods are necessary?
  3. Are there any specific contraindications to triptans and ergot preparations for this type of aura? Please justify your answer.
  4. Choose the optimal preventive treatment tactics.

                  Case 7:
Patient: Woman, 29 years old.

• Anamnesis: Severe migraine attacks without aura occur exactly 1-2 days before the onset of menstruation and continue for the first two days of the cycle. Headaches do not bother the rest of the cycle. These attacks respond poorly to standard analgesics.
• Task:
  1. Diagnose: "Pure menstrual migraine" or "Menstruation-associated migraine"? Explain.
  2. Suggest a strategy for stopping the attack, taking into account its severity.
  3. Develop a short-term (perimenstrual) prophylaxis plan. Include medications and dosage regimen.
  4. When should continuous preventive therapy be considered?

                            Case 8
Patient: Male, 50 years old.

• Anamnesis: She has a history of episodic migraines. The frequency of attacks has increased over the past two years. She currently takes sumatriptan up to 15-20 times per month. She complains of almost daily, dull, pressing headaches, accompanied by typical migraine attacks 3-4 times per week.
• Task:
  1. Formulate a complete diagnosis, including both conditions.
  2. Explain to the patient the concept of rebound headache.
  3. Create a step-by-step patient management plan that includes discontinuing the offending drug (triptan).
  4. What is bridge therapy and when is it used in the detox process?

                         Case 9:
Patient: Male, 38 years old.

• Anamnesis:Periodically, he experiences episodes of complete but reversible vision loss in one (right) eye, which he describes as a "draping shutter." These episodes last about 10-15 minutes, after which vision is fully restored. This is followed by a moderate headache in the forehead.
• Task:
  1. Make a preliminary diagnosis.
  2. What life-threatening condition should be considered in differential diagnosis first (amaurosis fugax)?
  3. Create an examination plan that includes consultations with related specialists and instrumental methods.
  4. What are the treatment and prevention tactics?

                      
                     Case 10:
Patient: A 35-year-old woman was taken in by ambulance.

• Anamnesis: Her typical migraine attack has been going on for four days now, without any clear intervals. The pain is excruciating, 10/10 on the VAS scale, accompanied by repeated vomiting. She took ibuprofen, paracetamol, and sumatriptan at home, without any effect. Upon examination, she was dehydrated, lethargic, and had severe photophobia and phonophobia.
• Task:
  1. Formulate a diagnosis.
  2. Describe your course of action and treatment plan in a hospital setting.
  3. List the drugs used to relieve migraine status (including nonsteroidal anti-inflammatory drugs, antiemetics, corticosteroids, etc.).
  4. Create a discharge plan to prevent relapse.