Neurology - New Note (Winkel)

Neurology- New Note History: * Patient presents with recurrent headaches, described as pulsating and localised to the left temporal region, occurring 2-3 times per week for the past 3 months. Headaches typically last 4-6 hours, rated 7/10 on the pain scale, and are often preceded by visual aura involving shimmering lights. Associated symptoms include photophobia, phonophobia, and occasional nausea. Over-the-counter paracetamol provides minimal relief. Patient denies any prior neurological issues or similar headache patterns. Past History: * Medical: Hypertension, diagnosed 5 years ago, well-controlled with medication. * Surgical: Appendectomy, 10 years ago, uneventful recovery. * Hospitalisations: None related to neurological conditions. * Social: Non-smoker, occasional alcohol use (1-2 units/week). Works as an accountant, reporting high work-related stress. No recreational drug use. * Family: Mother has a history of migraines. Paternal grandmother had a stroke at age 70. Medications: * Lisinopril 10mg once daily * Multivitamin once daily Allergies: * Penicillin (rash) Examination: * Vital Signs: * BP: 128/78 mmHg * HR: 72 bpm * RR: 16 breaths/min * Temp: 36.8°C * Physical Examination Findings: * General: Alert and oriented x3, well-nourished. * Mental Status: MMSE 29/30 (minor recall deficit). * Cranial Nerves: II-XII intact. Pupils equal, round, and reactive to light. Extraocular movements full. No facial asymmetry. Hearing intact bilaterally. Gag reflex present. * Motor System: Strength 5/5 bilaterally in all four extremities. No pronator drift. Tone normal. No involuntary movements. * Sensory System: Intact to light touch, pinprick, vibration, and proprioception in all extremities. * Reflexes: Biceps, triceps, brachioradialis, patellar, and Achilles reflexes 2+ bilaterally. Plantar reflexes downgoing. * Coordination: Finger-to-nose and heel-to-shin smooth and accurate. Romberg negative. Tandem gait steady. * Gait: Normal, no ataxia or spasticity. * Investigation Results: * Blood tests (FBC, U&Es, LFTs): All within normal limits. * MRI Brain (performed prior to consultation): Unremarkable, no structural abnormalities or acute pathology. Impression: 1. Migraine with Aura: Based on the classic presentation of recurrent pulsating headaches, visual aura, photophobia, phonophobia, nausea, and family history. The severity and impact on daily life warrant further management. Plan: * Investigations: * Consider EEG if headaches become more frequent or if atypical features develop. * Medical Treatment: * Acute treatment: Sumatriptan 50mg, take one tablet at the onset of headache, repeat dose after 2 hours if needed (max 2 doses/24 hours). * Prophylactic treatment: Propranolol 20mg twice daily, titrate up to 40mg twice daily if tolerated and needed after 2 weeks. * Lifestyle Modifications: * Stress management techniques, including mindfulness exercises. * Regular sleep schedule and avoidance of known migraine triggers (e.g., certain foods, bright lights). * Hydration and regular meals. * Referrals: * None at this time. * Follow-up Appointments: * Review in 6 weeks to assess response to prophylactic medication and sumatriptan, and to discuss any side effects. Monitor headache frequency and severity using a headache diary. Additional Notes: Patient education provided regarding the nature of migraine with aura, differentiating it from other headache types, and the importance of medication adherence. Explained that sumatriptan is for acute relief and propranolol is for prevention, highlighting potential side effects of each. Instructions provided for monitoring headache characteristics and to seek urgent care if new or worsening neurological symptoms occur, such as sudden severe headache, weakness on one side of the body, speech difficulties, or changes in consciousness. Emphasis on maintaining a headache diary to track effectiveness of treatment. Patient expressed concerns about the impact of migraines on her work productivity, which was addressed by discussing prophylactic options and potential adjustments to work routine.