(Disclaimer: This article is for general science purposes only, and the relevant information in the following content has been processed to protect patient privacy)
Abstract: The patient, a 26-year-old female, was prone to headache symptoms since childhood, and a slight lack of attention would cause headache, which was unbearable in severe cases, accompanied by nausea and vomiting. Recently, she came to the hospital, and after completing relevant examinations to exclude intracerebral lesions, a clear diagnosis of migrainous head wind was made. After the diagnosis was clear, the patient was given a combination of Chinese and Western medicine, and after standardized medication, the patient’s condition was stable and her headache symptoms were relieved.
Basic information】Female, 26 years old
Disease Type】Headache
Hospital】Shandong Provincial Third Hospital
Consultation time】May 2019
Treatment plan】Western medicine (Zolmitriptan tablets, Aminophen dihydrocodeine tablets) + Chinese medicine (Zaozheng San)
[Treatment period] 2 weeks of outpatient medication, follow-up after 1 month
Treatment effect】Stable condition, headache symptoms have improved
I. Initial consultation
A young woman had just joined the workforce, but her headaches had been bothering her since she was a child, and she had unbearable headaches when she blew, which were more likely to be triggered during menstruation. She had previously undergone brain MRI without any significant abnormalities and was considered to have migraine headache. The patient’s diagnosis was clear, and there were no positive signs in the neurological examination.
II. Treatment history
The patient was admitted to the hospital to improve blood tests such as routine blood, liver and kidney function, ion, lipids, blood glucose, cardiac enzymes, etc. No significant abnormalities were found except for high lipids. The complete cranial CT examination did not show any significant abnormality, the complete EEG examination was normal EEG, and the complete foam test was negative. Combined with the patient’s medical history and the characteristics of the attack, the preliminary diagnosis of migraine was made, and the Western medical name of the disease was vascular neuropathic headache. Zolmitriptan tablets and aminophenedihydrocodeine tablets were recommended for pain relief. The patient’s headache was completely relieved on the 3rd day after taking the medicine, but he came to the clinic again 1 week later and still had a mild headache. Repeatedly taking painkillers stimulated the stomach more and caused stomach pain, so he was given Chinese medicine Zaozheng San to regulate the headache for 1 week, and the headache was relieved better.
III. Treatment effect
Migraine, also known as vasoneurotic headache, is one of the common clinical primary headaches, more common in women and partly related to heredity. The patient’s headache symptoms were significantly relieved after taking pain medication from the outpatient clinic, and the headache symptoms were completely improved by the third day, but the disease is characterized by recurrence of headache symptoms after stopping the medication. The patient’s long-term use of pain medication was irritating to the gastrointestinal tract, which could easily induce gastritis and gastric ulcer, etc. Therefore, at the later follow-up, the patient was given Chinese herbal medicine for 1 week, and the patient’s symptoms improved. 1 month later, the patient was followed up by telephone and had no special discomfort.
IV. Notes
We are glad that the patient’s headache symptoms were relieved after treatment. Migraine is more likely to be associated with genetic factors, as well as with endocrine and metabolic factors, and is likely to appear during menstruation or before menstruation. Patients should avoid spicy, stimulating and greasy diet, avoid blowing wind and getting cold, keep emotional stability and ensure good sleep during the medication period. Pay attention to whether the headache improves during the medication period, and pay attention to whether there are symptoms such as dizziness, confusion and double vision during the headache. If they appear, they should go to the hospital to improve cranial magnetic resonance examination to exclude intracerebral lesions, such as encephalitis and cerebral infarction. In this case, the patient had irregular life and rest, but after rational arrangement of diet and rest habits, the number of headache attacks was reduced and the symptoms were alleviated, and the combined treatment of Chinese and Western medicine was effective.
V. Personal insight
Migraine is one of the common diseases in daily life, and it should be taken seriously if it recurs, and active medication can improve the symptoms. In this case, the patient used a combination of Chinese and Western medicine to achieve more satisfactory results. Patients should follow up regularly at the hospital and arrange their life rationally to avoid aggravation of the disease. If migraine recurs even after taking medication, patients are advised to actively seek medical advice to exclude encephalitis, cerebrovascular lesions, congenital heart disease, etc.