Chronic Migraines | Figure 1

Chronic Migraines
28 y/o male patient came into the clinic I work at complaining of chronic and debilitating migraines. Hx of Traumatic brain injury resulting in cognitive and motor deficits since age 9. Has tried Topamax, Fioricet, Verapamil, and oral NSAIDS with poor relief. Currently on Norco for migraines and chronic back pain. Brain MRI pending. 2016 CBC revealed a hemoglobin level of 13.4 and hematocrit of 42. Follow up lab 1 year later revealed hemoglobin level of 14.4 and hematocrit of 43. Patient was referred out for therapeutic phlebotomy and states that he has had significant reduction in the frequency of his migraines and associated pain. Referred to hematology. I had never heard of this treatment for migraines before so I did some research (Love medicine)! Of course it wasn't specifically for the migraines...what is DDx for this patient and what would be your treatment methods?

The problem
There is increasing evidence that people who have undergone brain surgery experience significant pain. This pain can have serious consequences including raised blood pressure, agitation, prolonged recovery time and an increased risk of long‐term headaches. Research studies have looked at different drugs in an attempt to reduce the risk of pain for these people. There is now more evidence about pain reduction options for adults undergoing brain surgery but there remains uncertainty as to which options work best.

The question
This review aimed to determine which drugs provide the best chance of reducing pain for adults undergoing brain surgery, by collecting and combining the results of studies that looked at pain‐relieving drugs for this patient group. To provide an accurate answer to this question, only studies conducted in accordance with an approved high standard were included. Studies published in different languages and countries were included in order to obtain as much information as possible.

In addition to determining which drugs were best at preventing or reducing pain after brain surgery, this review attempted to determine additional information such as how much additional pain‐relieving treatment was required in addition to the treatment under study; whether participants' pain was adequately controlled or not; how drowsy the participants were; what side effects they experienced; and how long they needed to stay in intensive care and in hospital. This review also considered whether some treatments worked better when given before or after surgery or for people undergoing different approaches to brain surgery.

The results
A total of 43 eligible studies, (42 complete and one still in progress), were found. Of the 42 completed studies (3548 participants), 10 studied injections of local anaesthetic into the scalp, 12 studied injection of local anaesthetic around specific scalp nerves, 8 studied nonsteroidal anti‐inflammatory drugs (NSAIDs), 4 studied dexmedetomidine, 4 studied acetaminophen aka paracetamol), 2 studied opioid drugs, 3 studied gabapentin or pregabalin (anti‐seizure drugs that can also be used for pain relief) together with 1 study each of local anaesthetic injected into the veins, local anaesthetic injected into the jaw and the drug flupirtine.

Sufficient information was abstracted to calculate the overall pain‐preventing effects of the following: local anaesthetic injections around the surgical wound, local anaesthetic injections around specific scalp nerves, NSAIDs, acetaminophen, dexmedetomidine and pregabalin or gabapentin. When only high‐quality studies were examined: NSAIDs reduced pain up to 24 hours after surgery, dexmedetomidine and local anaesthetics injected around specific scalp nerves reduced pain in the first 12 hours after surgery, pregabalin or gabapentin reduced pain in the first 6 hours after surgery and local anaesthetic injections around the surgical wound significantly reduced pain 48 hours after surgery, but did not affect pain at earlier time points.

When the timing of injection of local anaesthetics was examined, local anaesthetics injected around specific scalp nerves provided better early pain relief (first 6 hours) when injected after surgery and better late pain relief (12 and 24 hours) when injected before surgery.

The following interventions were also found to reduce the need for additional pain‐relieving drugs: local anaesthetics injected around specific scalp nerves and dexmedetomidine. Gabapentin or pregabalin was found to reduce the risk of nausea and vomiting after surgery.

Acetaminophen was not found to prevent pain after brain surgery or reduce the need for additional pain‐relieving drugs.

Insufficient evidence was found to determine whether any of these drugs made the participants more or less drowsy, affected how long they needed to stay in intensive care or whether different drugs worked better for adults undergoing different approaches to brain surgery. The overall quality of the evidence that contributed to the results of this review was assessed and judged to be 'high' for pain‐reducing effects of NSAIDs, 'moderate' to 'low' for pain‐reducing effects of dexmedetomidine, acetaminophen, pregabalin and gabapentin and local anaesthetics injected around specific scalp nerves and ' low' to ' very low' for pain‐reducing effects of local anaesthetic injections around the surgical wound, additional pain relief requirements and risk of nausea and vomiting after surgery.

13 week update on our favorite mom (y'all are so persistent, and I love it)! Everything is going great for them, and the baby is growing like a weed! They opted for Harmony testing, which came back negative for Trisomy 13, 18, and 21, and we found out the baby is a girl! They are very excited! No more ultrasounds until 18 week anatomy scan. Poor mom is majorly struggling with migraines :( Rx'd fioricet today, and she will call tomorrow to follow up.

69yo female came today for an initial appointment, with complaints of an itchy and painful foot where she has her thumb (and extending a little bit down the middle of her foot). It is just on her left foot. And what's stranger is that it generally only happens at night time when her feet are hot. There are no lesions present on her foot. It looks the same as her right foot, no erythema, no swelling etc. This has been occurring for 8 years now, she can't pinpoint exactly what has caused it and has tried and seen multiple people to try fix this. A couple of medical history details:

She is allergic to elastoplast, but does not recall actually having used it 8 years ago. Her GP has also done dopplers for her blood flow and blood tests and they have all come back normal. Only things that relieve it are ice, cortisone cream (aristocort) and painkillers (which she is currently taking panadeine forte for her arthritis and now this foot). Any one seen or had any cases like this? Thanks in advance!

Not quite a mystery to the standard of @synapse10, but perhaps a useful case for students/non-physicians. There is one piece of information missing from the below which was critical to clinching the diagnosis prehospital, can you tell me what it is? 50's year old female presents with a headache that began the previous afternoon whilst driving and had gradually worsened. The pain was throbbing in nature and unilateral (left side). There was mild photophobia and nausea, with no other associated symptoms or constitutional features. Scored as severe but had taken only paracetamol, previous headaches had responded well to cocodamol.

Afebrile, no nuchal rigidity, generally presenting as quite well with unremarkable vital signs. CNS finds no abnormalities and other neurology grossly intact. No recent trauma.