Migraine Headache Case Study

Chief Complaint

Migraine headaches.

History

Patient is a 19-year-old right-handed white male who presents with his mother for evaluation of frequent headaches. He did not have headaches prior to two grade 1 concussions while playing football in 2012. At that time, he had a normal MRI. He has been having headaches since. He did see Kent Logan, MD in 2012, at which point he was describing weekly headaches with photophobia, phonophobia, and nausea. At that time, according to Dr. Logan's notes, there was no aura with his headaches. He noted that trying one of his mother's Imitrex helped with the headache, so he was given a prescription for 50 mg. He was also diagnosed as having a whiplash injury, at that time. He did undergo physical therapy for his neck. He also was complaining of some short-term memory problems at that time, but neuropsychology testing was negative. He has not followed up with Dr. Logan since then. More recently, his headaches have been increasing in frequency. They are located in the left retrobulbar and super orbital area, but then will spread throughout the left side of the head and then bilaterally. The pain is steady when it is milder, but throbbing when it is worse, and it is worsened with exertion. There is photophobia, phonophobia, osmophobia, nausea. They can last one to two hours. Most often, he does have

Social History

He does not smoke. He does not drink alcohol. He is at Great Bay studying liberal arts.

Family History

Mother and maternal grandmother with migraines, breast cancer in the family, diabetes, SLE, fibromyalgia.

Past Medical History

He does have vasovagal syncope 15 to 20 times a year or more.

Panic attacks three to four times a week.

He did have Burkitt's lymphoma at three years old and underwent chemotherapy. He was told that he would have cardiac issues after that, but follow up EKGs have been normal.

Allergies

Cephalosporins, amoxicillin,