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Cases
New Headaches in a Middle-Aged Man
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Case
A 43-year-old right-handed white man presents to his primary care physician because of headaches. He states that the headaches began 2.5 months ago at a frequency of every other week, although the last 2 were separated by only 8 days. The most recent headache occurred 3 days ago. He describes the headaches as throbbing; usually right sided; and associated with photophobia, nausea, and vomiting. He denies any visual changes, aura, or prodrome associated with the headaches. He also denies any sensory, motor, or visual changes. The patient reports that the headaches resolve when he is able to sleep. The patient asks about migraine therapy and wonders whether he is a candidate for one of the new triptan medications he is hearing so much about in the lay press.
On further questioning, the patient reports that he had migraine headaches as a teenager; these were identical to the current headaches. Twenty-five years ago, he underwent a complete workup, and nonenhanced brain CT findings were negative. At that time, he was treated with both prophylactic and abortive migraine medications, with varying success. His last migraine headache prior to the one 3 months ago occurred when he was 25 years of age. His medical and surgical histories are otherwise negative. He is not taking any medications except for minimal doses of over-the-counter (OTC) ibuprofen during his last 2 headaches; however, these were not effective. The patient does not smoke cigarettes or drink caffeinated beverages.
Findings from the patient’s general physical and screening neurologic examinations are normal.
What is the most appropriate course of action?
A. Prescribe triptan abortive medication and review its proper use with the patient.
B. Start prophylactic migraine medication in conjunction with triptan abortive medication.
C. Completely review this patient’s case and consider further diagnostic studies before prescribing further migraine therapy.
D. Refer the patient to a neurologist.
E. Both C and D are correct.
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***** HINT *****
Headache classification is critical to this diagnosis.
***** ANSWER *****
Right frontal lobe arteriovenous malformation (AVM): The correct answer is E. This patient’s clinical presentation is worrisome. His past history of migraine headaches is a red herring. Evaluating this patient in cooperation with the treating neurologist is the best course of action. The workup should include neuroimaging. The old adage that any new or changing headache in a patient older than 40 years is a bad headache until proven otherwise applies to this case.
A subsequent MRI is performed. The axial T1-weighted image shown above is consistent with the right frontal AVM. Interestingly, AVMs with a migrainelike presentation have been extensively described in the literature. The consulting neurologist and neurosurgeon should determine the subsequent care of this patient.
Because of the location of the lesion, the normal screening neurologic findings are not unexpected. Mass lesions in the right frontal lobe can be clinically silent, even after they attain a significant size. A more rigorous neurologic examination in these patients may still reveal more subtle neurologic abnormalities.
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Author:
Agapito S. Lorenzo, MD
Associate Professor, University of Nebraska and Creighton University, Departments of Neurology
Editor:
Nicholas Lorenzo, MD
Consulting Neurologist, Chief Editor, eMedicine Neurology
Source
http://emedicine.com
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