What is the diagnosis and management for a 33-year-old male with migraines and a history of TBI presenting with transient visual loss and diaphoresis?

From the Guidelines

This patient is experiencing migraine headaches with a concerning episode of temporary vision loss, and I recommend continuing Excedrin at the onset of symptoms rather than waiting until the headache intensifies, but limiting use to fewer than 10 days per month to prevent medication overuse headache, as suggested by the most recent guidelines 1. The patient should identify and avoid personal migraine triggers including stress, certain foods (aged cheeses, processed meats, alcohol, chocolate, MSG), irregular sleep patterns, and dehydration. A headache diary tracking symptoms, triggers, and medication effectiveness would be beneficial. The patient should seek immediate medical attention for any "worst headache ever," neurological deficits lasting more than 60 minutes, or headache with fever, as these could indicate more serious conditions like stroke, aneurysm, or meningitis. The patient's history of TBI from an MVA 14 years ago and the new visual symptoms warrant consideration of preventive migraine therapy if episodes become frequent (>4 per month) or significantly impact quality of life. Preventive options include propranolol, topiramate, or amitriptyline, which would require further discussion with the patient's physician, and the choice of preventive treatment should be based on the patient's specific needs and medical history, as outlined in the guidelines 1. Additionally, the patient may benefit from non-pharmacological therapies such as relaxation training, biofeedback, or cognitive-behavioral therapy, as suggested by the guidelines 1. It is essential to educate the patient on the importance of realistic expectations and the potential need for a multimodal approach to therapy, including pharmacological and non-pharmacological treatments, as emphasized in the guidelines 1. The patient should be encouraged to maintain a headache diary and to seek regular follow-up with their physician to monitor the effectiveness of their treatment plan and make any necessary adjustments, as recommended by the guidelines 1. Overall, the management of this patient's migraine headaches requires a comprehensive approach that takes into account their individual needs, medical history, and lifestyle, and is guided by the most recent and highest-quality evidence, as outlined in the guidelines 1.

From the Research

Migraine Treatment and Warning Signs

• The patient's symptoms, such as pressure on both sides of the temporal area, sinus pain, and vision turning gray, are consistent with migraine headaches 2, 3, 4, 5, 6.
• The patient's past medical history of migraines and use of Excedrin, ibuprofen, and water to alleviate symptoms are also consistent with migraine treatment 2, 3, 4, 5, 6.
• The patient was advised to take Excedrin at the first sign of symptoms, rather than waiting, to optimize treatment outcomes 2, 3, 4, 5, 6.
• The patient was also warned about potential medication overuse if taken more than 10 days monthly 2.

Warning Signs Requiring Immediate Care

• The patient should seek immediate care if they experience the worst headache ever, neurological deficits lasting more than 60 minutes, or fever with headache 2, 3, 4, 5, 6.
• These warning signs may indicate a more serious condition, such as a brain tumor or other neurological disorder, and require prompt medical attention 2, 3, 4, 5, 6.

Treatment Options

• The patient's treatment options include over-the-counter medications such as acetaminophen, aspirin, and caffeine, as well as prescription medications like triptans 2, 3, 4, 5, 6.
• The patient's response to treatment may vary, and predictive models can help identify factors associated with better treatment outcomes 3.
• The combination of acetaminophen, aspirin, and caffeine has been shown to be effective in alleviating migraine headache pain and associated symptoms 4, 5, 6.