TEACHING CASE: MENOPAUSAL MIGRAINE

CASE PRESENTATION A 46-year-old right-handed woman presented to the Montefiore Headache Center with a history of episodic headaches since the age of 25. Her pain can be parietal, frontal, orbital, or holocranial; the pain can be bilateral or unilateral, switching sides between attacks, and described as throbbing, achy, dull, or pressure-like. The severity is graded anywhere between a 3 to a 10/10, and attacks typically last for 24 hours. Her headache frequency had been 1-2 attacks per month up until a few months ago, when the attack frequency escalated to 19 days of headache monthly. Associated symptoms include nausea, photophobia, phonophobia, and poor appetite. She also has discomfort from wearing contact lenses during her attacks. Any form of physical activity exacerbates her pain and she seeks relief by lying down in a dark, quiet room. Premonitory symptoms include sluggishness and vague neck discomfort. She has experienced a visual aura with approximately 25% of her attacks, characterized by seeing an ovoid area of flashing lights in the upper left hemifield, which evolves to a zig-zag and wavy-lined pattern, expanding over the central part of her visual field, lasting for 10-20 minutes and then resolving. After a 10to 20-minute pause, a typical headache would ensue. She has had visual aura in isolation 5 times in her life. Triggers include red wine, caffeine, flashing lights, and sleep deprivation.With approximately half of her menstrual cycles, she would have an attack on the day or 2 prior to her menses. Previous preventive medications only include a 2-month trial of riboflavin 100 mg daily. Ibuprofen had worked effectively in the past, leading to pain freedom within 2 hours; however, the effect has waned and it no longer provides any significant benefit. Past medical history includes temporomandibular dysfunction and bruxism, for which she wears a night guard, and childhood asthma, which resolved. She is not depressed or anxious. Her mother has a history of multiple sclerosis and migraine without aura that abated with menopause. Menarche occurred at 10.5 years of age, and her menses had been quite regular until 6 months before presentation, when they became unpredictable, occurring from 3-week to 2-month intervals (Fig.). Although she had mild irritability and anxiety in the 3 days prior to her menses in the past, these symptoms have become much more prominent, and now encompass significant insomnia and mood swings as well. She has also started to experience occasional hot flashes. She was headache-free during her 3 uncomplicated pregnancies. Her headaches have caused her to miss no days of work, but she feels much less productive than in months or years past. She works as an internist. She ISSN 0017-8748 doi: 10.1111/j.1526-4610.2009.01600.x Published by Wiley Periodicals, Inc. Headache © 2010 the Author Journal compilation © 2010 American Headache Society