A 30-Year-Old Woman with a History of Episodic Migraine Headaches

question 504

Multiple Choice

A 30-year-old woman with a history of episodic migraine headaches comes to the office due to worsening of her headaches.  She started having infrequent migraine headaches in her early twenties.  However, her migraine headaches have become more severe over the past 1 year and have started to occur >15 days/month.  She has been taking ibuprofen on a daily basis for months to treat the headaches, which have only worsened and now occur on a daily basis.  Recent MRI of her brain showed no abnormalities.  She has not had any fevers, neck stiffness, vision changes, head trauma, double vision, dysarthria, dysphasia, weakness, numbness, or difficulty with balance.  Her headaches are not affected by changes in head position, cough, or Valsalva maneuvers; but are made worse by physical activity and are associated with photophobia, and nausea.  She works as a secretary and has needed to take leave from work due to her severe headaches.  She does not use tobacco, alcohol, or illicit drugs.
Her seated blood pressure is 128/76 mm Hg and pulse is 76/min.  Her BMI is 32 kg/m².
Neurologic examination shows no abnormalities except for marked photophobia.  Which of the following is the most appropriate next step in the management of this patient?

• A)Discontinue ibuprofen, start a short oral steroid taper, and prescribe topiramate
• B)Order a lumbar puncture for opening pressure
• C)Order MR venography of the head
• D)Start acetazolamide
• E)Start topiramate

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A collection of initiatives, including programs, public work projects, financial reforms, and regulations, that were implemented by President Franklin D. Roosevelt in the United States throughout the 1930s as a reaction to the Great Depression.

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