Severe Headache in a Patient With Migraines

Vital Signs

• Temperature: 98.2 °F, axillary

• Blood Pressure: 138/68 mmHg

• Heart Rate: 87 beats per min (bpm) – normal sinus rhythm on telemetry

• Respiratory Rate: 14 breaths per min

• Pulse Oximetry: 99% saturation on room air

Focused Physical Examination

A quick exam revealed a middle-aged female sitting in bed with a pair of sunglasses on. She was in moderate distress secondary to pain. The patient’s cranial nerve testing did not demonstrate any abnormalities, but the penlight used for the exam worsened her distress. She did not have any temple tenderness. She was alert and orientated. She demonstrated full strength of all extremities. Heel-shin testing was within normal limits. Her cardiac and pulmonary exams were benign. Her abdominal exam revealed several clean, dry, and intact bandages. Bowel sounds were present in all four quadrants. She denied any numbness, tingling, double vision, and blurry vision. She endorsed some mild abdominal discomfort from her recent surgery. The patient reported that she has a history of occasionally getting migraines that would require her to come to the emergency room for treatment. She stated that her current headache felt similar to her previous migraine episodes.

Interventions

Since there were no focal neurological deficits on the physical exam, vital signs were stable, and the headache was similar in presentation to her previous migraines, it was determined that the patient was experiencing her typical migraine. No emergent imaging or labs were obtained. She was given a 1 L bolus of lactated ringers, ketorolac 30 mg IV, ondansetron 4 mg IV, and diphenhydramine 25 mg IV. Then, 2 h later, the patient’s nurse contacted the intern on the rapid response team to let her know that the patient’s headache had completely resolved.