Tina dreaded those 3 days every month
1. 32-year old Tina was happy & cheerful for 27-28 days every month, however, she feared facing the remaining 3-4 days. She hopelessly wished that those days never ever came, but that was not possible.
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1. 32-year old Tina was happy & cheerful for 27-28 days every month, however, she feared facing the remaining 3-4 days. She hopelessly wished that those days never ever came, but that was not possible.
#medTwitter #neurotwitter
2. Tina used to get severe headaches that occurred only on 3-4 days every month. These days were 1-2 days prior to her menses or during the first two days of menses. She never experienced headache on other days of the month. She had regular periods and had a 2-year old child too.
3. Headaches were severe with a score of 7-8 on visual analog scale (where 10 is the most severe pain, and 0 is absence of pain). Tina had nausea, vomiting and dizziness associated with headache.
Headaches lasted 24-36 hours and they left her completely incapacitated.
Headaches lasted 24-36 hours and they left her completely incapacitated.
4. Headaches took a heavy toll on Tina's personal and professional lives. She was unable to give quality time to child and husband on those 3-4 days.
She was also not in a position to go to office. She was a software professional and had to routinely take leave on 2-3 days/month.
She was also not in a position to go to office. She was a software professional and had to routinely take leave on 2-3 days/month.
5. Tina consulted gynecologist and physician, but the treatment did not help much. Gynecologist told her that everything is normal. Physician tried pain-killers, which didn't help Tina much. She also tried meditation and yoga, which helped a bit but not significantly.
6. Frequent sick leaves created a negative impact about her in office. Colleagues had to work extra, doing Tina's share of job too.
Tina looked for support from her boss (a woman), but was dismissed saying "every woman has menses, are you someone special, who needs leave?"
Tina looked for support from her boss (a woman), but was dismissed saying "every woman has menses, are you someone special, who needs leave?"
7. Tina had resigned to her fate, and felt there is no hope left. She felt sad, anxious and had lack of sleep too. She was depressed. These resulted in her getting more severe headaches. When she reviewed with her physician, she was asked to consult a neurologist.
8. I reviewed Tina's history.
Headaches started 2 yrs back (post-delivery). She had no prior headaches. They occurred on two days before menses or on first two days of menses. There was no aura prior to headache. There were no other precipitating factors.
Diagnosis was clear now
Headaches started 2 yrs back (post-delivery). She had no prior headaches. They occurred on two days before menses or on first two days of menses. There was no aura prior to headache. There were no other precipitating factors.
Diagnosis was clear now
9. The diagnosis was catamenial migraine, also called pure menstrual migraine (PMM).
Headaches in PMM can occur 2 days prior to menses or during first 3 days of menses (-2 to +3).
Migraine during this period may be triggered by oestrogen withdrawal.
Headaches in PMM can occur 2 days prior to menses or during first 3 days of menses (-2 to +3).
Migraine during this period may be triggered by oestrogen withdrawal.
10. No tests were needed to confirm the diagnosis, as the diagnosis of PMM is based on history. I explained the diagnosis to Tina and discussed the treatment options.
She opted to take medical treatment on those 5 days every month. Daily medicines are not needed.
She opted to take medical treatment on those 5 days every month. Daily medicines are not needed.
11. At 1-month review, she reported headache on only 1 day. During the next 3 months, she had 0-1 day headache per month. Moreover, the duration of headache was only 12 hours, and severity too had reduced.
Tina's quality of life improved, and she didn't require leave from work.
Tina's quality of life improved, and she didn't require leave from work.
12. Take home message
*Headaches occurring on 2 days prior to menses or during first 3 days of menses during 2 out of 3 previous months is suggestive of pure menstrual migraine.
*Medical treatment on those 5 days results in excellent relief from headache & better quality of life.
*Headaches occurring on 2 days prior to menses or during first 3 days of menses during 2 out of 3 previous months is suggestive of pure menstrual migraine.
*Medical treatment on those 5 days results in excellent relief from headache & better quality of life.
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