Headaches/Vomiting

[twtw]

Hi,
I am a medical student. A good friend approached me with some complaints recently. She is a 23 yr old asian female complaining of headaches and nausea/vomiting for the past 2.5 weeks. She is experiencing headaches intermittently, sometimes tension type, sometimes unlateral throbbing and migraine like. She also experiences vomitting (with or without nausea), BUT the vomiting does NOT coincide with the headaches. It tends to occur a day or even 2 afterward. In the past 20 days she has experienced roughly 4-5 episodes of headaches, but she used to have headaches once every few months or even just once a year. The headaches last 1-5 hours and usually occur after midday (afternoon or evening). Napping often helps relieve the headache. She has experienced 3-4 intermittent days of vomiting. On some of these occasions, she could vomit between 1 to 5 times that day.

Pregnancy has been ruled out due to menstruation. She went to a walk-in clinic last week, papilledema was not detected at the time, the physician said it could potentially be migraines. I'm suspcious of this diagnosis because my impression is that migraine induced vomiting/nausea should coincide with the headache, not occur afterwards. My impression is that migraine variants (e.g. cyclic vomiting syndrome) tend to be quite rare.

No visual disturbances recently, but 4 years ago she had 2 transient incidents of sudden transient bilateral visual loss lasting 1-5 seconds (typical of papilledema induced sudden visual loss), however, ophtho exam turned up completely normal (done by ophthalmologist).

No balance problems, no ataxia, no aphasia, no seizures, no memory/cognitive issues, headache not worse in morning, headache not worse with movement. She has normal BMI.
No history of travel or recent infection, no other GI system symptoms
Family history of migraines is not known.

She is planning to see a doctor again soon, but I have several concerns.

1) Is it common for migraine-related vomiting/nausea to occur one day after the headache phase
2) With the given presentation and information, what is the likelihood of serious pathology? (e.g. brain tumor, increased ICP)

[DrBhumikaMD]

Hi,
No it is not common for migraine related vomiting to occur one day after the headache, but then there are exceptions to every rule. What could be a possibilty is that she still has the headaches at the time of the vomiting but tends to ignore it maybe ( am i making sense?) Is there a trigger factor for the migraines nad do the headaches resolve with painkillers? Has she tries taking anti reflux and anti nausea medication for her symptoms? Is is possible that too many pain killers or medication during the headache phase might be causing the vomitings later? The exact diagnosis would need a neurologist consultation but the chances of it being a brain tumour seem less. She should consult a neurologist and get the investigations he suggests done.

[noops01]

Hi,

I think most likely diagnosis would be migraine. You have not mentioned if she took any medication for the headache and did it help. I would suggest she undergo CT scan and MRI of brain to rule out serious pathology.