A 25-Year-Old Pregnant Woman With Worsening Headaches

Nancy Hammond, MD

Disclosures

June 07, 2018

Editor's Note:
The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a future Case Challenge, please contact us.

Background

The patient is a 25-year-old woman with a history of headaches since age 15 years. She is currently 24 weeks pregnant. Her pregnancy so far has been uneventful other than worsening headaches. Hours prior to getting a headache, she has a strong sense of malaise and fatigue with mild nausea. Occasionally, prior to headache onset, she will see a scintillating, zig-zag light in one visual field. This light can be in either visual field. The visual symptoms last 15-20 minutes, and then she experiences a severe unilateral, pulsatile headache.

She has associated symptoms of nausea, occasional vomiting, photophobia, and phonophobia. Initially, headaches were occurring about once per month; however, they have increased in frequency since she became pregnant and now occur about once a week. Other than occurring more frequently, the headaches are similar in quality to the headaches she had prior to becoming pregnant. Each headache will last for 6-8 hours, and sleep will relieve the headache.

She is otherwise healthy and takes no medications, other than occasional ibuprofen for her headaches. Prior to pregnancy, she had good headache relief with sumatriptan. She works as an accountant and misses work about two times a month due to headaches. She denies any use of tobacco or illicit drugs. She reports occasional alcohol use but also notes that alcohol use can provoke a headache. She has not used alcohol since she has been pregnant. Her family history is remarkable for similar headaches in her mother and brother.

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