linical Case Study: Migraine PatientAuthor/ Source of Case Presentation:SummaryA 34-year-old woman with worsening migraines, now occurring 4-5 times a month. Headaches are severe, unilateral, and temporal, with aura, nausea, and photophobia. She misses work and struggles with household chores and childcare during attacks. Naratriptan is partially effective, causing her to consider switching medications due to weight gain from valproic acid.Chief Complaint: “This new medication is not working for my migraines. My headaches are worse around my period and I have gained 10 pounds!”Case Presentation:Presenting to the neurology clinic is a 34-year-old female who states that she used to get about two migraines every month; however, she recently went back to work full-time and has two young children, ages 3 and 5, to care for. Since then, the frequency of her migraines has increased to about four to five per month. She states her migraines usually occur in the morning and are more frequent around her menses. Her typical headache evolves quickly (within 1 hour) and involves severe throbbing pain, which is unilateral and temporal in distribution. Her headaches are preceded by an aura, which consists of nausea and pastel lights flashing throughout her visual field. Photophobia occurs frequently, and vomiting may occur with an extreme headache. She reports experiencing severe migraine attacks that cause her to miss one day of work each month. She is unable to complete household chores and has a difficult time caring for her children on the days she has severe migraine attacks. She also complains of having mild migraine attacks lasting three days per month, during which her productivity at work and home is reduced by half. She typically has to retreat to a dark room and avoid any noise, or the severity of the migraine increases. She rates her migraines as 7–8 on a headache scale of 1–10, with ten being the worst. At her previous visit to the Neurology Clinic 3 months ago, she was prescribed naratriptan 2.5 mg orally to be taken at the onset of headache. However, naratriptan has not been effective for half of the migraines she has had in the last three months. During two of the attacks, she experienced partial pain relief, with the pain returning later in the day. She mentions that she was prescribed naratriptan when the Cafergot she was taking stopped working. She states she has taken her medications precisely as advised. She was started on valproic acid at her last clinic visit for headache prophylaxis and has noticed a 10-lb weight gain. She inquires about switching from valproic acid to another medication.Physical Exam Findings:Migraine with aura since 29, previous medical workup, increasing an EEG and a head MRI, demonstrated no PVD, CVA, brain tumor, infection, cerebral aneurysm or epileptic component. Vital Signs: Vital SignsVital Signs- BP: 142/86 mmHg- HR: 76 bpm- RR: 18- Temp: 37.2°C- Weight: 75 kg- Height: 5’3” Family Medical History: The patient's mother has a history of migraines, hypertension, and Type II Diabetes. The patient's father also has a history of migraines.Social History: The patient is a mother to two boys aged 3 and 5. She recently started working full-time as a secretary.Lifestyle: The patient stopped smoking 3 months ago but occasionally consumes caffeine. She does not consume alcohol or use illicit drugs.Diagnostic TestsLaboratory ResultsSerum Electrolytes:Sodium (Na): 142 mEq/LPotassium (K): 4.2 mEq/LChloride (Cl): 101 mEq/LCarbon Dioxide: 23 mEq/LHematology:Hemoglobin: 13.0 g/dL (Reference Range: 12-16 g/dL)Hematocrit: 40% (Reference Range: 36-46%)WBC: 8.0 × 103 / mm3 (Reference Range: 5-10 × 103 / mm3)Differential Count:Blood Urea Nitrogen (BUN): 12 mg/dL (Reference Range: 10-20 mg/dL)Serum Creatinine (SCr): 0.8 mg/dL (Reference Range: <1.5 mg/dL)Glucose (Glu): 95 mg/dL (Reference Range: <140 mg/dL)AST: 23 U/L (Reference Range: 5 - 40 U/L)ALT: 23 U/L (Reference Range: 29 - 33 U/L)Alk Phos: 35 U/L (Reference Range: 44 – 147 U/L)Platelet: 302 × 103 / mm3 (Reference Range: 150–450 × 103 / mm3)Previous Drug Therapies:Abortive therapies:Simple analgesics, NSAIDs and Cafergot (good efficacy until 3 months ago)Narcotics ( good efficacy, but puts her “ out of commission for days” )Midrin (no efficacy)Naratriptan (minimal efficacy)Prophylactic therapies:Valproic acid 500 mg daily (weight gain)Propranolol 20mg BID (increase episodes of dizziness and light headedness; patient discontinued medication)Treatments for mild depression (for 8 months):Phenelzine 15mg po TID (minimal efficacy, discontinued 2 months ago)Sertraline 50 mg po at bedtime (recently started 1 month ago)