Patient Case Presentation

1. Dr. Jennifer E. Heasley
Mylan School of Pharmacy
Duquesne University
Ambulatory Care Resident
August 25, 2009

2. Patient Information
TK is a 27 year-old African American female
Generally good health
No known drug allergies

3. Chief Complaint
Seen at Catholic Charities on 7/29/09 complaining of
migraines
Also currently complains of:
Fatigue
Dysmennorhea

4. History of Present Illness
Diagnosed with migraine headaches when she was a
teenager
Tried Advil 200mg and Tylenol 325 mg in the past with no
relief
Currently taking Imitrex 50mg tablet
Nausea with migraine; vomiting occasionally after taking
Imitrex tablet
Patient does not like injections

5. History of Present Illness
Migraines occur mainly with menses, but also at other
times during the month
(+) Floaters with migraine
(+) Photophobia with migraine
(+) Phonophobia with migraine
Pain scale 7 out of 10

6. Past Medical History
Chlamydia
10/21/08: Treated with Doxycycline 100mg
1 tablet PO BID x 7 days
Eczema (since childhood)
5/19/09: Given 0.1% Triamcinolone acetonide topical
cream
Apply to affected area QID

7. Social History
Denies smoking and illicit drug use
“Social Drinker”
Lives alone; single
Currently in school for Early Child Development

8. Family History
Breast Cancer
Mother
Maternal grandmother
Paternal grandmother
Multiple Sclerosis
Mother
Sister
Hypertension
Mother

9. Current Medication List
Imitrex 50mg tablet
1 PO PRN migraine. May repeat in 2 hours if no relief.
Naproxen 500mg tablet
1 PO BID PRN migraine
Triamcinolone acetonide 0.1% topical cream
Apply to affected area QID (for eczema)

10. Labs (7/29/09)
Temp: 98F
⁰
BP: 126/74
past readings: 116/90 (7/10/09)
121/80 (6/30/09)
127/80 (5/19/09)
Weight: 236 lbs
past readings: 236 lbs (7/10/09)
234 lbs (6/30/09)
236 lbs (5/19/09)

11. Labs (cont.) – 7/1/09

Test Procedure
Result
Reference Range
/ /
High Low Normal
RBC 4.43 mill/mcl3.80-5.10 mill/mcl Normal
Hgb 11.5 g/dL11.7-15.5 g/dL LOW
Hct 34.1% 35.0-45.0% LOW
MCV 77.0 FL 80.0-100.0 FL LOW
MCH 26.0 PG 27.0-33.0 PG LOW
MCHC 33.7 g/dL32.0-36.0 g/dL Normal
Platelet Count233
thous/MCL
140-400 thous/MCL Normal
TSH 1.66 mU/L0.40-4.50 mU/L Normal

12. Problem List
Migraines
Nausea
Anemia
Dysmennorhea
Fatigue
Obesity

13. What should we recommend for
TK?
Migraines/Nausea
Imitrex
Available as an oral tablet, and injection, and a nasal spray
Recommend switching from Imitrex oral tablet to Imitrex 5mg/actuation
nasal spray
Use 10mg (5 in each nostril) at onset of headache. May repeat in 2
hours if needed. Do not exceed 40mg in a 24 hour period.
#48 sprays with 3RF
Bridges to access program (GlaxoSmithKline)
Also recommend switching directions of Naproxen 500mg tablet
Tk 1 PO TID with food. Start 2 days before to 3 days after the start of
menses

14. What should we recommend for
TK?
Migraines
Prophylactic therapy?
Group 1 –most evidence and least side effects
Propranolol
Timolol
Amitrypyline
Depakote
Topamax

15. What should we recommend for
TK?
Migraines
Nonpharmacological Therapy
Lifestyle changes
Regular routines for eating, sleeping, and exercise
Avoidance of triggers
Alcoholic beverages
Caffeinated beverages
Chocolate
Stress/Overexertion
Bright Lights
Odors
Pollution
Eyestrain

16. What should we recommend for
TK?
Anemia
Ideally, would like to obtain a serum ferritin to confirm iron
deficiency
Recommend ferrous sulfate 325 mg (65mg iron)
Take 1 tablet PO TID with food
If constipated can use OTC colace
#90 with 3RF
Purchase OTC

17. What should we recommend for
TK?
Dysmennorhea
The changing of directions of the Naproxen 500mg tablet
for migraines serves a double purpose
The naproxen 2 days prior to 3 days after onset of menses should
help with both migraines and dysmennorhea

18. What should we recommend for
TK?
Fatigue
TSH normal
Could be due to either migraines or anemia, or both
Treat anemia/migraines and monitor fatigue

19. What should we recommend for
TK?
Obesity
Recommend regular exercise
Start with walking 10-30 minutes 3x a week and increase as
tolerated
Dietary Restrictions
May also help with migraines

20. References
Clinical Pharmacology. Tampa, FL: Gold Standard; 2009.
http://cp.gsm.com. Updated August, 2009 . Accessed August 23,
2009.
“Evidence-Based Guidelines for Migraine Headache in the Primary
Care Setting: Pharmacological Management for Prevention of
Migraine.” 2009. US Headache Consortium.
“Evidence-Based Guidelines for Migraine Headache in the Primary
Care Setting: Pharmacological Management of Acute Attacks.”
2009. US Headache Consortium.
Lay, Christine and Richard Payne. “Recognition and Treatment of
Menstrual Migraine.” The Neurologist. 2007; Volume 13. 4:197-204.
2007
“Understanding the Prevalance of Migraines: Diagnosis, Disease,
and Treatment.” APHA Special Report. 2007. American Pharmacists
Association.

21. QUESTIONS?