Scenario 2: Patient is a 24-year-old female administrative assistant who comes to the emergency department with a chief complaint of severe right-sided headache. She states that this is the sixth time in the last 2 months she has had this headache. She says the headaches last 2–3 days and have impacted her ability to concentrate at work. She complains of nausea and has vomited three times in the last 3 hours. She states, “the light hurts my eyes.” She rates her pain as a 10/10 at this time. Ibuprofen and acetaminophen ease her symptoms somewhat but do not totally relieve them. No other current complaints.

 Assignment (1- to 2-page case study analysis)

In your Case Study Analysis related to the scenario provided, explain the following:

• Both the neurological and musculoskeletal pathophysiologic processes would account for the patient presenting these symptoms.
• Any racial/ethnic variables that may impact physiological functioning.
• How these processes interact to affect the patient.

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Solution

Concepts of Neurological and Musculoskeletal Disorders

Case overview

A 24 year old female administrative came with complaints of a severe right-sided headache, which has been there for the past two months. She further reports that this is the 6^th time she has experienced the pain. The headache lasts 2-3 days, has affected her ability to concentrate at work, and is associated with photophobia, nausea, and vomiting (three times in the last three hours). She rates her pain as 10/10 and is partially relieved by ibuprofen and acetaminophen.

Neurologic and pathophysiologic processes

Given the patient presenting complaint, the most likely diagnosis is a migraine. This is because it is characterized by frequent incidents of headache, which are most unilateral and is commonly accompanied by sensory and visual symptoms commonly regarded as the aura which arises before or after the headache. According to (Dodick, 2018), migraine headaches occur in phases;

• The premonitory phase begins as soon as three days prior to the onset of the migraine headache and involves an interaction between changes in homeostasis and the commencement of migraine. During this phase, migraine is commonly triggered by alterations in homeostasis, and the common symptoms include; photophobia, mood changes, fatigue, muscle tenderness, and others. There is an alteration of the sympathetic and parasympathetic function, therefore, interfering with the autonomic function in the central nervous system.
• The aura phase is present in approximately 1/3 of the migraine attacks. The most common symptom of this phase is visual alteration. Other symptoms include; motor, speech, and sensory disturbances and disturbance of the higher cortical function. In this phase, there is induction and dispersion of cortical spreading depression, which is characterized by a slowly generating wave of depolarization in glial membranes and neuronal cells that is followed by blocking of cortical activity for about 30 minutes coincides with the beginning and progression of aura symptoms.
• The headache phase is characterized by throbbing pain resulting from trigeminovascular pathway activation. Signals from activated nociceptors that innervate the cranial blood vessels are transmitted to the trigeminal bipolar neurons and transported to the cortical and thalamic areas. Transmission of the signals from the neurons causes the release of vasoactive inflammatory substances, which cause inflammation of the meninges leading to the characteristic throbbing pain in migraine.

Racial/ethnic variables that impact physiologic functioning

According to research, Europeans are more prone to get migraines. This is because the emigration of humans from Africa to the colder parts of Europe saw them develop a gene that is more prone to getting migraines. A researcher in evolutionary genetics discovered that genetic mutation is more prevalent among Europeans (Viganò et al., 2019). The researchers did a study that focused on analyzing human beings’ adaptation to different environmental factors, particularly on the effect of temperature, by studying the genetic patterns of the TRPM8 gene, a receptor in human beings that senses cold temperatures and cooling effects menthol.

Using genome data to backtrack through the tens of thousands of years of genetic evolution, the researchers discovered that the farther towards the north, the more likely the genetic mutation linked to migraines becomes. This indicates that as human beings traveled north from Africa, they adapted to colder temperatures but, in the process, made themselves more susceptible to migraines.

How the processes interact to affect the patient

Factors such as stress, weather changes, hormonal changes, and others are leading triggers for migraines as they affect- the trigeminal nerve that courses through the mouth and eyes. As a result, it releases neurotransmitters that can induce pain and activate the brain stem and the cerebral cortex leading to the interference of daily activities, including concentration. The characteristic right-sided pain is often a result of the involvement of the ophthalmic trigeminal ganglion fiber, which causes eye pain and photophobia.

 References

Dodick, D. W. (2018). A Phase-by-Phase Review of Migraine Pathophysiology. Headache: The Journal of Head and Face Pain, 58, 4–16. https://doi.org/10.1111/head.13300

Li, W., Bertisch, S. M., Mostofsky, E., Buettner, C., & Mittleman, M. A. (2019). Weather, ambient air pollution, and risk of migraine headache onset among patients with migraine. Environment International, 132, 105100. https://doi.org/10.1016/j.envint.2019.105100

Viganò, A., Manica, A., Di Piero, V., & Leonardi, M. (2019). Did Going North Give Us Migraine? An Evolutionary Approach on Understanding Latitudinal Differences in Migraine Epidemiology. Headache: The Journal of Head and Face Pain, 59(4), 632–634. https://doi.org/10.1111/head.13520

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