Case Studies
CASE 1 - LAWYER WITH RECURRENT HEADACHES
A 42-year-old successful lawyer describes new onset headaches- At the end of the summer last year experienced nocturnal headache attacks that lasted 1-2 hours. The headaches were always localised over the right side on his eye and temple area. During the attack he was restless and his right eye looked swollen, with tears and redness. He described a blocked nose and flushing of his face. He did not find relief with paracetamol, aspirin, or ibuprofen.
He attended AE a couple of times and was told this could be stress related due to his demanding job. The attacks were daily up to 4 times a day (usually at the same time during the night 2 am and 6 am) and lasted for 3 months. He has come to consultation today as his headaches have recurred.
This gentleman is suffering from CLUSTER headaches which is one of the most debilitating headaches. He describes periods of remission (episodic). There are different strategies to treat the acute headache and prevention treatment including short term (transitional) and long-term management (see headache section-Cluster headache).
CASE 2 - 18-YEAR-OLD WITH DEBILITATING HEADACHES AND VISUAL SYMPTOMS
Sarah is 18 and has always been prone to feel sick when traveling by car or boat. Her motion sickness has been quite debilitating. From the age of 14 she complained of frequent headaches during her menstrual periods- she had school absences during this time as her headaches were associated with dizziness and feeling quite tired, fatigued after the headache bout. She had severe vomiting during the attacks and were not relieved by common analgesia or antiemetic medication.
Sarah is describing a typical history of migraine (menstrual migraine) with associated dizziness and severe nausea/vomiting. There are different strategies to prevent and treat this disabling condition including contraception medication changes or adding migraine preventives or long acting Triptans to prevent her attack. (See headache – migraine section).
CASE 3 – 65-YEAR-OLD WITH HEADACHES AFTER HORSE RIDING
Sam is 65-year-old businessman from Harrogate that developed stereotyped attacks -sharp shooting pain on the back of his head (occipital) and upper neck (cervical) after horse riding at the Yorkshire Dales. He complained of frequent (4-6 times a day) – “electric shock” pain for 1 minutes followed by numbness and burning sensation-
He is waking up am with neck stiffness-cervical pain- and tenderness on palpation of the right occipital area and has noted limitations for neck flexion and rotation.
This gentleman is clearly describing attacks of Occipital Neuralgia and cervicogenic headaches. Investigations and specific treatment strategies should be put in place. Please see section – Headaches – occipital neuralgia and section treatment Greater occipital nerve block.
CASE 4 – 32-YEAR-OLD HOUSEWIFE WITH DIZZINESS AND A HEADACHE
Adele has been suffering from disabling neurological symptoms over the past year. She describes attacks characterised by external “dizziness” (Vertigo like) - can last up to 6-8 hours à Seen by Ear Nose Throat (ENT) consultants and prescribed anti sickness medications that have not helped. Her attacks of dizziness are associated with light, sound, smell and motion sensitivity These attacks are associated with significant pressure inside her ears, runny nose and tinnitus and most of them end up with a bilateral throbbing pain behind her eyes and ears and significant nausea and vomiting. She needs to sleep and prefers to be in a dark room
Adele has debilitating symptoms of Vestibular migraine. This condition is usually misdiagnosed as vertigo. There are preventive and acute treatments that improve significantly the quality of life of patients suffering from these attacks. Please see headache section- migraine.
CASE 5 – EPISODIC TO CHRONIC MIGRAINES WITH AURA
A 22-year-old student currently – on minipill- describes a history of motion/travel sickness as a child. Since a teenager she has experienced episodes of visual symptoms lasting for 45 minutes (grey zig zag lines on the periphery) Her headaches have been sporadic and she would normally complain of right sided pain on her forehead and Jaw discomfort with throbbing characteristics, associated with sound and smell sensitivity and feeling queasy (between 6-12 hours).
Over the past 6 months patient has noted increase in frequency and now has 2-3 disabling episodes per week – Ibuprofen and paracetamol not effective
She has kept a diary showing 20 monthly headache days.
Over the past few weeks, she has attended Accident and Emergency 2 times- where apart from reassurance she has had CT head that was reported as normal
This young lady is describing a typical history of episodic migraine transforming into CHRONIC migraine which is quite common and affects about 2% of patients affected with migraine. There are non-specific and more recently specific antiCGRP treatments for patient with episodic and chronic migraine. Please see headache section- migraine
CASE 6 - ATYPICAL HEADACHE WITH A SPECIFIC TREATMENT
Melissa is a 29-year-old woman – history of migraine with aura during her teens. Seen initially by her GP. The patient describes recurrent left sided dull jaw and temple pain. Over the past 8 weeks – continuous sensation of “swelling” and sensitivity to touch (allodynia) on the left temple, cheek, and jaw.
In addition to the continuous pain, she describes recurrent attacks of stabbing/throbbing pain on the left cheek (V2) and jaw (V3) that could last for 4-6 hours associated with sensitivity to light, accompanied by tears, runny nose and sensation of” fullness” of her ear on the same side of the pain. Feels anxious/restless - most exacerbations occur at nighttime and some during sleep.
Seen by dentist and had 2 teeth removed not resolving her issues Her GP has prescribed Carbamazepine for her facial pain and it was NOT effective at 200 mg TDS and takes oral diclofenac at the onset of the pain attack with minimal improvement.
Melissa has been suffering from this new headache over the past few months without a successful treatment. Her general practitioner has been treating her suspecting trigeminal Neuralgia however the description of the headaches seems to be in keeping with a treatable condition known as HEMICRANIA CONTINUA. This type of headache is treatable and a trial of INDOMETACIN should be carried out. Patients would normally respond to this treatment. Please see more information at – Headaches – Hemicrania Continua section.
CASE 7 - ANTONIA 70-YEAR-OLD WITH PAINFUL TIC LIKE SYMPTOMS
Antonia is a well and fit 70-year-old retired schoolteacher. Over the past 4 months she is complaining of attacks of electric shock, burning pain over the left cheek area that lasts for seconds. She can have up to 10 attacks in a day. Interestingly most of her attacks occur whilst brushing her teeth and drinking cold drinks. She has noted that after taking a shower and drying her face the painful attacks can be triggered as well. She has tried paracetamol and ibuprofen to prevent the attacks. Her relatives told her that during an exacerbation she tends to contract her face muscles and looks like she has developed tics on her face.
Antonia describes sharp short lasting painful attacks in the face that are generally triggered by external and intraoral triggers. Antonia needs to be further investigated and a treatment to control her Trigeminal Neuralgia symptoms should be put in place. For more information about Trigeminal Neuralgia please visit – Facial pain section.