Note 2

The previous patient has been diagnosed with probable migraine headache and treated with amytriptilene 50 mg. at bedtime and zolmitriptan 2.5 mg via nasal spray – up to two doses for an acute headache.  She comes back to see you a few months later and reports that she has had no headaches since the last visit.  However she has been feeling “really sleepy all day” and feels like she isn’t functioning so well at work.  She also says that about a month ago she started to see the “wavy lines” and feel a little nauseous so she took one dose of the zolmitriptan and her complaints resolved without ever having a headache.  Your exam is essentially the same as the last time except that she is not having pain on EOMs or when the penlight is shone into her eyes.   She has a problem list in her chart and #3 is Migraine Headache – Uncomplicated with visual aura

 

 

Subjective:

A few months ago, 36y/o female came for a visit due to probable migraine and was treated with amytriptilene 50 mg at bedtime and zolmitriptan 2.5 mg via nasal spray – up to two doses for an acute headache.

In recent visit, pt states feeling “really sleepy all day,” seeing “wavy lines” and having mild nausea.

Symptoms were relieved by reducing the dose of zolmitriptan 2.5 mg via nasal spray from two to one dose.

 

Observation:

Physical exam is essentially same as the last time except one difference noted below.

Eye: no pain on EOMs

 

Assessment:

Most likely having adverse reactions from taking 2 doses of zolmitriptan 2.5 mg via nasal spray since her symptoms were relieved by reducing the dose to only one.

 

Plan:

Continue the pt on just one dose of zolmitriptan 2.5 mg via nasal spray.