A 33-year-old woman presents with a severe headache that began 5 hours ago. The patient reports that the headache is unilateral on the left side and endorses nausea, an episode of vomiting, and photophobia. Neurologic examination reveals normal muscle strength and no sensory loss.
Which of the following is the best next step in the management of this patient?a. Propranolol
Chlorpromazine. The patient in this question is likely having an acute episode of a migraine headache. Migraines are characterized by unilateral, pulsating pain that is often associated with photophobia and an aura of neurologic symptoms prior to the onset of the headache. Acute attacks can range in duration from 4 to 72 hours. Acute treatment and primary preventive treatment vary in migraine headaches. Acute attacks are best treated with intravenous antiemetic medications (chlorpromazine and prochlorperazine) and/or triptans (sumatriptan). The American Academy of Neurology actually recommends NSAIDs and caffeine/acetaminophen as first-line treatment for mild–moderate migraines. However, chlorpromazine is the right answer for this question since this patient’s symptoms are consistent with a moderate– severe migraine (vomiting, photophobia). Given that this patient presents with vomiting, chlorpromazine is the best choice since it can be given in IV form.
(A, B) Propranolol and amitriptyline are both excellent medications used for migraine prophylaxis, not for acute episodes. These would be appropriate to give to the patient after her acute migraine episode resolves to prevent further attacks. (D) Verapamil is a calcium channel blocker that is the first-line medication for cluster headache prophylaxis. However, this patient is having a migraine, not a cluster headache. Cluster headaches typically involve pain around the eye with eye watering, nasal congestion, and swelling. Cluster headaches are much more common in men and acute treatment involves inhaled oxygen and sumatriptan.
Finally, another commonly tested type of headache is a tension headache, which is bilateral and typically involves greater than 30 minutes of pain without photophobia or aura. Tension headaches respond well to NSAIDs; however, amitriptyline can be given for chronic tension headaches.