Case: Just Another Migraine?

00:01 Okay, last case.

00:03 So, we’ve got an older patient here.

00:05 I’ve got a 75-year-old woman.

00:06 She has a one-day history of headache.

00:08 Well, it’s just one of my migraines, she explains.

00:11 Sounds pretty benign.

00:12 Let’s get a little bit more.

00:15 So, she has a long history of unilateral migraine headaches, which previously resolved with just a high-dose non-steroidal anti-inflammatory drugs.

00:24 However, the character of this pain is different.

00:26 It’s very concentrated over her temple specifically and it's actually tender to palpation there.

00:34 So, just with that limited history alone, what's the next best step in the management for this patient? And again, you could pause and think about this for a second.

00:44 So, is it, A, just change the type of NSAID she is taking? Maybe that will make a difference.

00:49 Just reassurance.

00:50 She's right, it’s probably just a recurrent migraine and just continue with that expectant management that’s been working for a while.

00:56 Do you initiate maybe a new drug, like a triptane instead of giving her an NSAID? Maybe that’ll be more effective for a migraine headache? Or, D, do we send her to the laboratory immediately and we also initiate corticosteroids? So, this one is to throw you off.

01:11 Indeed, not every case of acute management just needs reassurance and it will probably resolve with time because this is unusual.

01:21 New headaches and different types of headaches always should raise attention for potential red flags.

01:27 In this case, you're seeing unilateral temporal-based pain in a 75-year-old woman with the area actually tender to palpation.

01:35 All of that is very concerning for the diagnosis of…temporal arteritis.

01:41 Very good.

01:42 So, temporal arteritis can have severe complications, particularly in terms of risk of thrombosis and ischemia immediately, so she could lose her vision, she can have a stroke.

01:54 Therefore, immediate laboratory evaluation for simple things like a Sed rate and a CBC for the potential for temporal arteritis and she should not leave your clinic without a prescription for corticosteroids because the application of corticosteroids can dramatically reduce that risk of complication.

02:12 So, she’ll need close follow-up and an initiation of treatment right away.

02:17 So, this is just an example, but I thought it was a keen example to give you an idea that not every case can be managed just with expectant management and reassurance.

02:27 But, certainly, I think for USMLE exam and the way I think about patient care, the answer many times, it's not every answer, and so the trick for you is to watch for high-risk conditions.

02:38 Now, what do those conditions include? I think headache is a high-risk condition.

02:43 So, always pay attention to it.

02:44 Chest pain, while it’s usually benign, still a high-risk condition.

02:48 New neurological symptoms.

02:50 This isn’t the patient with diabetes for 20 years, who has bilateral tingling in the feet, but I’m talking about somebody who has monocular blindness or a left facial droop, something new going on that's acute.

03:05 Think about stroke, you think about masses or other severe CNS disorders.

03:11 Or – and these are often found incidentally – new lesions or masses in organs such as the skin or the breasts.

03:17 I’ve got this mole and, yeah, it seems to be growing and changing.

03:20 Then it bleeds and falls off and then it comes back again.

03:23 The first thing I'm worried about is cancer.

03:25 Now, that's – is it going to be cancer? Unlikely.

03:29 But the first thing I'm going to worry about is cancer.

03:32 And anytime somebody comes in with a – I feel a new mass in my breast, particularly if they’re over 50 and particularly if they are higher risk for breast cancer because of a family history or something like that.

03:43 These are the high-risk conditions just to name a few.

03:46 But some of the more common ones that we see should alert you to the fact that you might need to really go and perform a more thorough workup here.

03:55 You may need to order advanced therapy for this patient right from the get-go, not everything can just be a wait-and-see approach.

04:02 So, hopefully, you found these cases beneficial.

04:05 Now, we’ll move into the acute care module and you can see how this plays out with some real cases.

04:10 Thank you.