This document summarizes a medical case involving a 27-year-old African American female patient who presents with migraines, fatigue, and dysmennorhea. Her medical history and lab results are presented. The assistant recommends switching the patient's migraine medication from oral tablets to nasal spray, adjusting a pain medication, treating her anemia with iron supplements, addressing her obesity through diet and exercise, and considering preventative migraine treatments.

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: 98⁰F 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/mcl 3.80-5.10 mill/mcl Normal Hgb 11.5 g/dL 11.7-15.5 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/dL 32.0-36.0 g/dL Normal Platelet Count 233 thous/MCL 140-400 thous/MCL Normal TSH 1.66 mU/L 0.40-4.50 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?