By Alexander Mauskop, MD, FAAN
Director, New York Headache Center
New York, NY
A 32-year-old woman was referred to the headache clinic by her internist. She has been suffering from severe headaches since the age of 15. The attacks have become more frequent and occur two to three times a month. Her headaches were usually unilateral (one-sided) and were always preceded by colorful zigzag lines on one side of her visual field. The visual disturbance lasted 30 minutes and was followed by dizziness, which she described as room spinning, nausea and difficulty speaking. The dizziness and difficulty speaking lasted for an hour, while the headache, which started while she was still having difficulty speaking and dizziness, persisted for the rest of the day. Ibuprofen and acetaminophen were not very effective, while a butalbital/caffeine/acetaminophen combination prescribed by her internist worsened the nausea.
The internist did not prescribe a triptan (i.e., Imitrex®, Maxalt® or Relpax®) because of the neurological symptoms. The patient was in good general health with no significant past medical history. She was not taking any medications. Her family history was positive for similar headaches in her mother, until she reached menopause. The patient was working fulltime and was married with two children. She did not drink excessive amounts of caffeine (one cup of coffee a day) and did not smoke. Her physical examination was normal. An MRI scan of her brain was also normal. At the headache clinic, she was prescribed rizatriptan (Maxalt), which provided excellent relief of her headache, although she still had an hour of disability while waiting for the aura symptoms to resolve. To prevent her attacks, the patient was advised to start regular aerobic exercise, undergo a course of biofeedback, and take a supplement containing magnesium, feverfew and riboflavin. Continue Reading