A 58-year-old female with a history of headaches, depression, anxiety and anorexia nervosa, sought out an internist after hearing him give a talk on migraine headaches. She had suffered from headaches since age 21, with a postmenopausal remission. Now, however, her headaches were a daily occurrence. During her initial visit with the internist, the patient described a series of recent losses in her life, including a break-up with a long-time boyfriend. The headaches were affecting her mood and her ability to sleep. She was taking Doxepin for insomnia & depression.
Her physical exam, which included a brief neurological evaluation, was normal. The internist attributed her headaches to the recent stress in her life, and diagnosed her with 1) transformed migraine headaches, 2) chronic dysthymia, and 3) chronic insomnia. After the patient started on Depakote as a prophylactic for her headaches, she experienced some short-lived relief.
During the following five months, the pain returned in full, dosages of the initial medications were adjusted, exams were normal, and the internist eventually switched the medication to Zoloft and Ambien. When he referred the patient to counseling, she did not return.
The patient then presented to her PCP with complaints of daily migraine headaches. Her PCP attributed her headaches to stress and her caffeine intake. She was given Tylenol, Klonopin, and aspirin.
A year later, the patient again saw her PCP for the headaches, which were now waking her up. She patient was started on Buspar. Counseling was again recommended, which the patient soon started.
Within four months—two years after her first complaint to the internist—the patient self-referred to a neurologist for evaluation of her headaches. Her neurological exam was normal. The neurologist diagnosed rebound headaches and advised the patient to alternate between Tylenol and Ibuprofen.
Two weeks after this neurology appointment, the patient was found slumped over the steering wheel at a red light. A CT scan at the hospital revealed a large, right temporal parenchymal hematoma. There was also a right subdural hematoma. The patient had fixed pupils and continued to be unresponsive. CTA revealed multiple aneurysms, (the largest in the middle cerebral artery). After emergency surgery, the patient developed asystole for 30 minutes. The family declared her a DNR, and the patient was pronounced dead.