A 46-year-old white male comes in for evaluation of his migraine headache management. 


  • A 46-year-old white male comes in for evaluation of his migraine headache management.
  • His medical history is inclusive for hypertension and a myocardial infarction at the age of 39. He was diagnosed with migraine headaches three years ago.
  • Current medications include Losartan 50 mg a day, verapamil SR 100 mg at bedtime, Carvedilol 25 mg a day, Lipitor 40 mg a day, Topamax 50mg a day
  • He has been admitted to the hospital for migraine management 3 times over the last 6 months. Inpatient admissions have ranged anywhere from 3 to 6 days. Management strategies utilized during the hospitalization include IV corticosteroids, IV Dilaudid and IV magnesium sulfate.
  • BP 132/84, P 82, R 15
  • Skin: pink, warm, dry
  • Neuro: alert and oriented, CNs II – XII intact
  • Cardio: radial and pedal pulses 2+, heart regular rate and rhythm without murmur or gallop
  • Lungs: clear to auscultation
  • Abdomen: large, non-distended, active bowel sounds all quadrants, non-tender to palpation

Please develop a discussion that responds to each of the following prompts. Where appropriate your discussion needs to be supported by scholarly resources. Be sure to include in-text citations in the context of the discussion and provide a full reference citation at the end of the discussion.

Utilize the information provided in the scenario to create discussion post.

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Construct your response as an abbreviated SOAP note (Subjective Objective Assessment Plan).

Structure your ‘P’ in the following format: [NOTE: if any of the 3 categories is not applicable to your plan please use the ‘heading’ and after the ‘:’ input N/A]

Therapeutics: pharmacologic interventions, if any – new or revisions to existing; include considerations for OTC agents (pharmacologic and non-pharmacologic/alternative); [optional – any other therapies in lieu of pharmacologic intervention]

Educational: health information clients need to address their presenting problem(s); health information in support of any of the ‘therapeutics’ identified above; information about follow-up care where appropriate; provision of anticipatory guidance and counseling during the context of the office visit

Consultation/Collaboration: if appropriate – collaborative ‘Advanced Care Planning’ with the patient/patient’s care giver; if appropriate -placing the patient in a Transitional Care Model for appropriate pharmacologic and non-pharmacologic care; if appropriate – consult with or referral to another provider while the patient is still in the office; Identification of any future referral you would consider making

Support the interventions outlined in your ‘P’ with scholarly resources.

Please be sure to validate your opinions and ideas with citations and references.


Optimizing Migraine Headache Management in a Patient with Cardiovascular Comorbidities: A Comprehensive Approach


The patient is a 46-year-old white male presenting for evaluation of his migraine headache management. He has a medical history of hypertension and a myocardial infarction at the age of 39. The patient was diagnosed with migraine headaches three years ago. He has had multiple hospital admissions for migraine management in the past six months, with durations ranging from 3 to 6 days (Keddis & Garovic, 2010). During these admissions, he received IV corticosteroids, IV Dilaudid, and IV magnesium sulfate. The patient reports a significant impact on his quality of life due to the frequency and severity of his migraines.


Vital signs are within normal limits with a blood pressure of 132/84 mmHg, pulse rate of 82 beats per minute, and respiratory rate of 15 breaths per minute. The physical examination reveals normal findings in the skin, neurological system, cardiovascular system, respiratory system, and abdomen.


Migraine headaches: The patient has a history of migraine headaches for the past three years. The frequency and severity of the migraines have led to multiple hospital admissions over the last six months, indicating inadequate management.

Hypertension: The patient has a history of hypertension, for which he is currently taking Losartan 50 mg daily and Carvedilol 25 mg daily.

Myocardial infarction: The patient had a myocardial infarction at the age of 39, which suggests the need for careful consideration of pharmacologic interventions for migraines, considering his cardiovascular history.



Pharmacologic interventions: Given the inadequate control of migraines with the current regimen, a revision of the patient’s medication regimen is warranted. Considering the patient’s cardiovascular history, it is important to avoid medications that may increase the risk of adverse cardiovascular events (Silberstein, 2015). The addition of a migraine-specific medication, such as a triptan (e.g., sumatriptan), may be considered. However, caution should be exercised and a thorough assessment of cardiovascular risk factors should be conducted before initiating triptan therapy.

Non-pharmacologic interventions: In addition to pharmacologic interventions, non-pharmacologic approaches should be incorporated into the management plan. These may include stress reduction techniques, lifestyle modifications (such as regular sleep patterns, exercise, and healthy diet), and identifying and avoiding triggers that may contribute to migraine attacks.


Medication adherence: Emphasize the importance of medication adherence and discuss potential side effects and drug interactions associated with the revised medication regimen.

Trigger identification and avoidance: Educate the patient about common migraine triggers, such as certain foods, hormonal changes, stress, and lack of sleep. Encourage the patient to keep a headache diary to identify triggers and modify lifestyle accordingly.

Lifestyle modifications: Provide information on the importance of maintaining a regular sleep pattern, engaging in regular exercise, and following a healthy diet to help manage migraines.

Follow-up care: Schedule a follow-up appointment to assess the patient’s response to the revised medication regimen and discuss any concerns or new developments.


Collaborative Advanced Care Planning: Engage in shared decision-making with the patient to develop an individualized treatment plan based on his preferences and goals (Vahdat et al., 2014). Discuss the potential benefits and risks of different treatment options, considering his cardiovascular history.

Referral: Consider a referral to a headache specialist or a neurologist with expertise in managing migraines, particularly in patients with cardiovascular comorbidities. A specialist can provide a comprehensive evaluation, including imaging studies if needed, and help optimize the patient’s management plan.

In conclusion, the patient’s inadequate control of migraines warrants a revision of his medication regimen, with consideration of migraine-specific medications and careful evaluation of cardiovascular risks. Incorporating non-pharmacologic interventions, educating the patient about triggers and lifestyle modifications, and considering consultation with a specialist can further enhance the management of his migraines.



Keddis, M. T., & Garovic, V. D. (2010). 38-Year-Old Woman With Hypertension, Headaches, and Abdominal Bruit. Mayo Clinic Proceedings, 85(7), 674–677. https://doi.org/10.4065/mcp.2009.0330 

Silberstein, S. D. (2015). Preventive Migraine Treatment. Continuum, 21, 973–989. https://doi.org/10.1212/con.0000000000000199 

Vahdat, S., Hamzehgardeshi, L., Hessam, S., & Hamzehgardeshi, Z. (2014). Patient Involvement in Health Care Decision Making: A Review. Iranian Red Crescent Medical Journal, 16(1). https://doi.org/10.5812/ircmj.12454 


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