You obtain a more detailed history and discover the following: During her teens, the patient’s headaches had always been associated with nausea and vomiting. For the past 10 years, although nauseated, she no longer vomited with her headaches. She felt an overwhelming sense of exhaustion and craved sweets the night before most of her headaches. When she was younger, the subject had missed an average of 1 day of school per month because of her headaches, having to remain in her bedroom with the lights out and the shades drawn. Her pediatrician recommended treating the pain with ice packs and acetaminophen, which afforded little or no relief. She believed the headaches resolved on their own, usually within 12 hours of onset. Her headaches were often triggered by stress, weather changes, and too little sleep, but these triggers were not consistent. Each month, however, usually 1 to 2 days before the onset of menstruation, the patient experienced a severe headache that could last for up to 2 days. These headaches were more severe than her other headaches and occurred each month. Over the years, the subject’s headaches have recurred at varying intervals. During her 2 pregnancies, however, she was relatively headache-free. At the present time, she reports 2 or 3 headaches monthly, one always in association with her menses. Because of these headaches, she consulted with her gynecologist, who recommended treatment of the acute attacks with naproxen sodium. However, the treatment worsened the nausea. He then gave the subject a prescription for a combination product containing acetaminophen, butalbital, and caffeine, which made her drowsy but did not abort the headaches. Past Medical History Unremarkable. Family History Positive for a mother and grandmother with “sick” headaches. Medical and Neurologic Examinations Normal. Diagnostic Workup The subject has never undergone a neuroimaging procedure and it is felt as to be not warranted at this time. What is your primary diagnosis now? What medication therapy would you initiate?
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