For each scenario, please provide the following:
• Identify the type of headache
• Write your specific prescription(s) for the patient. (This must include the medication name, dose, route, and frequency as well as any special instructions that apply as you would include when writing a prescription).
• Provide a rationale for your treatment plan.
• Describe the patient education you would provide in relation to your treatment plan.
• Support your plan and education for each scenario with a minimum of two scholarly references.
Scenario 1:
Ms. Jane Carter is a 28-year-old female who presents for evaluation of headaches. She is slightly pale and appears sensitive to the bright lights in the consultation room on exam. She reports “I’ve been getting these really bad headaches, and they are making it difficult to complete by work.”
Ms. Carter reports experiencing headaches intermittent since she was a teenager, but they are more frequent in the last six months. She is experiencing 4 to 5 headaches a month that are lasting from 24 to 48 hours each. The headaches are generally on the right side of her head and feel like a severe throbbing sensation which she rates as 8 out of 10 pain. She occasional has nausea and notices she is too sensitive to light and noise to continue to work. She states her visions seems odd and she will sometimes see zigzag lines in her vision for about 30 minutes before the headaches begin. She has tried Tylenol, ibuprofen and Excedrin over the counter without adequate relief. She is not currently taking any other medications.
Scenario 2:
Ms. Emily Parker is a 38-year-old female who presents for evaluation of recurring headaches. Ms. Parker appears alert but mildly fatigues and reports “I’ve been getting dull headaches almost every day which are very annoying.”
Ms. Parker has a history of mild to moderate headaches for the past six months that occur on four to 5 days per week and typically last for three to four hours. She describes the headaches as bilateral and starting at the back of the head, radiating to the forehead. The headaches are a dull, pressing headache with a sensation of something tightening around her head that she rates as a 5 out of 10 pain. She has tried acetaminophen over the counter when they come on, but this doesn’t seem to help. She does usually feel better if she can rest in a quiet room for an hour, but her job does not always allow her to do this.
Scenario 3:
Mr. James Thompson is a 46-year-old male who presents for evaluation of headaches. He reports “I’ve been having chronic difficulty with headache, and they seem to be getting worse.”
Mr. Thompson has a past medical history of hypertension and a myocardial infarction at the age of 29. He is currently taking losartan 50mg daily, verapamil SR 100mg daily, Carvedilol 25mg twice daily, Atorvastatin 40mg at bedtime and topiramate 50mg twice daily.
Mr. Thompson reports a history of headaches past 20 years and a previous diagnosis of migraines. He is currently taking topiramate 50mg twice daily for headache prevention, but reports that in the last four months the headaches have increased in frequency to four to five headaches per month and he has been taking Excedrin migraine OTC without relief. The headaches are described as a painful throbbing and pressure over the left temple and he rates them at a 9 out of 10 pain. The headaches tend to last for 12 to 24 hours at a time. His neurologic exam in the office is normal today.
Scenario 4:
Mr. Michael Davis is a 41-year-old male who presents to the clinic for evaluation of severe headaches. Mr. Davis appears distressed and exhausted and he is pacing in the exam room and occasionally rubbing his right temple. He reports “I’ve been having these horrible headaches on and off for the past few weeks. The come out of nowhere and feel like someone is stabbing me in the eye.”
Mr. Davis describes a two-week history of severe headaches occurring one to two times daily lasting for about 45 minutes to an hour each time. The headaches started up abruptly after a two-year headache-free period. He describes them as strictly unilateral, centering around his right eye and temple with excruciating, sharp, burning pain. They are severe and he rates them at 10 out of 10 pain. He also experiences some redness of the eye, watering of the eye and runny nose when the symptoms occur. Nothing seems to help when the headaches come on, though he’s tried Tylenol and ibuprofen. He has no other past medical history.
Rationale for Treatment Plan:
The prescribed medication, sumatriptan, is a selective serotonin receptor agonist (triptan) that works by constricting intracranial blood vessels and inhibiting the release of pro-inflammatory neuropeptides. This mechanism directly addresses the pathophysiology of a migraine attack, making it a highly effective abortive treatment. Triptans are considered a first-line therapy for moderate to severe migraines. Ms. Carter's failure to respond to over-the-counter NSAIDs (ibuprofen, Excedrin) indicates a need for a more specific abortive medication. Using sumatriptan at the onset of symptoms, including the aura, provides the best chance of aborting the headache before it becomes debilitating. Since her headaches are intermittent, an abortive therapy is more appropriate than a daily preventative medication at this time.
References: 1.
<div id="5c29007f-777e-407b-8919-4700d5a37452"></div>
D’Amico, D., & Curone, M. (2020). Triptans for the Treatment of Migraine: Current Evidence and Future Directions. CNS Drugs, 34(10), 1011–1026. 2. <div id="9806c9b3-468a-410a-85d8-4f24c3a296b4"></div> Silberstein, S. D., & Holland, S. (2018). Migraine: Diagnosis and Treatment. Neurologic Clinics, 36(3), 447–460.
Patient Education:
"Ms. Carter, based on your symptoms, it appears you have migraines. The medication I'm prescribing, sumatriptan, is specifically for migraines. You should take one tablet as soon as you feel a headache starting, even during the visual aura. This medication works best when taken early. If the headache doesn't go away completely, you can take a second tablet two hours after the first. However, do not take more than two tablets in a 24-hour period. This medication is not a painkiller for general headaches; it's a migraine-specific treatment. We'll monitor your headaches, and if they become more frequent, we can discuss a daily preventative medication."
Scenario 2: Ms. Emily Parker
Type of Headache: Tension-type headache. The symptoms of a bilateral, non-throbbing, dull, and pressing headache with a "tightening" sensation are characteristic of a tension-type headache. The mild to moderate pain rating (5/10) and the relief with rest also support this diagnosis.
Prescription:
Drug: Naproxen Sodium 220 mg tablets
Dose: 2 tablets (440 mg)
Route: Oral
Frequency: Take at the onset of headache.
Special Instructions: May take 1-2 tablets every 8 to 12 hours as needed for pain. Do not exceed 6 tablets in a 24-hour period.
Rationale for Treatment Plan:
Tension-type headaches are often managed with NSAIDs, which have proven effectiveness for mild to moderate pain. Ms. Parker has tried acetaminophen without relief, suggesting a need for a different class of OTC analgesic. Naproxen sodium is an NSAID that is effective for this type of headache. It is a reasonable first-line treatment due to its proven efficacy and over-the-counter availability. The goal is to provide her with a more effective abortive medication that she can take as needed.
References: 1.
<div id="f7b594b2-29e6-4299-8c67-27b9195b28d0"></div>
Bendtsen, L. (2018). Chronic Tension-Type Headache: An Update. Current Pain and Headache Reports, 22(4), 31. 2. <div id="96c340f1-611c-4e8c-8519-74e92a40738a"></div> Headache Classification Committee of the International Headache Society (IHS). (2018). The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia, 38(1), 1–211.
Patient Education:
"Ms. Parker, your headaches sound like tension-type headaches, which are very common. I am prescribing Naproxen, a type of anti-inflammatory medication that is often more effective for this kind of pain than Tylenol. Try taking two tablets as soon as you feel the headache starting. You can take more as needed throughout the day, but be sure not to exceed the total daily dose. In addition to medication, I recommend you try non-pharmacologic options like stress management techniques, stretching, and staying well-hydrated. If these headaches continue to be frequent and disrupt your work, we may consider a daily preventative medication."
Sample Answer
Scenario 1: Ms. Jane Carter
Type of Headache: Migraine with aura. The presence of a prodrome (sensory sensitivity), aura (visual disturbances like zigzag lines), unilateral throbbing pain, and associated symptoms like nausea and photophobia are all classic signs of a migraine. The duration of 24-48 hours and severe pain rating also fit the diagnostic criteria.
Prescription:
Drug: Sumatriptan 50 mg tablets
Dose: 1 tablet
Route: Oral
Frequency: Take at the first sign of a migraine attack. May repeat dose once after 2 hours if the headache is not resolved.
Special Instructions: Do not exceed 100 mg in a 24-hour period.