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Management Plan for Migraine Headache in a Male Adult

Migraine headaches, characterized by debilitating pain often accompanied by nausea, vomiting, and heightened sensitivities, are a common neurological disorder affecting millions worldwide. This case study delves into the comprehensive assessment and management of a 32-year-old male presenting with recurring severe headaches. The intricate nature of migraines demands an integrated strategy that incorporates tailored care, precise identification, and patient-focused learning. By combining historical patient data, comprehensive examinations, and contemporary medical wisdom, a customized care plan can be crafted to advance the patient’s quality of living (Evan et al., 2020). The integration of recent scholarly research enables the creation of a thorough management plan that addresses diagnosis, therapy, and patient engagement.

Most likely diagnosis based on history and physical exam: Migraine headache.

The patient presents with classic symptoms of a migraine headache: severe, unilateral pain that later encompasses the whole head, accompanied by nausea, vomiting, and heightened sensitivities to various stimuli such as light, sound, and smell (Evan et al., 2020). Given the absence of other significant medical history, and the presence of these aforementioned symptoms, a migraine headache without aura is the most plausible diagnosis.

Appropriate diagnostic tests and expected results

While migraines are often diagnosed based on clinical history and presentation, certain diagnostic tests can be utilized to rule out other causes:

Neurological Examination: This helps determine any neurological abnormalities. Expected result: No abnormalities (Bae et al., 2021).

Magnetic Resonance Imaging (MRI): An MRI can display detailed images of the brain, and can detect tumors, strokes, bleeding, and other brain abnormalities. Expected result: Normal brain structure.

Computed Tomography (CT) scan: This helps in visualizing the brain and can be utilized to detect tumors, infections, brain damage, bleeding, and other possible medical conditions. Expected result: No anomalies detected (Bae et al., 2021).

Medications and nonpharmacologic treatments


Pain relievers: These pain relievers can provide aid, but you must be careful not to endure adverse effects including headaches caused by overuse (Bae et al., 2021).

Triptans: e.g., sumatriptan. Blood vessel constriction and pain pathway obstruction are the mechanism employed by these medications.

Beta-blockers: These drugs offer protection against migraine attacks.

Antidepressants: Specific antidepressant medications can mitigate migraine episodes.

Nonpharmacologic treatments

Cognitive behavioral therapy (CBT): By using this resource, you can effectively address stress, a frequent migraine causative agent.

Biofeedback: Observing bodily functions can help people resume command over their health.

Acupuncture: A number of migraine patients find comfort through acupuncture interventions (Evan et al., 2020).

Massage therapy: Exercising can reduce migraine instances by easing muscular pressure.

Suggested consults/referrals

Neurologist: A consultation with a neurologist is recommended for a comprehensive evaluation, diagnosis confirmation, and development of a tailored management plan (Evan et al., 2020).

Registered Dietitian: To address dietary factors that may trigger or exacerbate migraine attacks, especially considering the patient’s irregular eating patterns.

Client education

The patient should be educated on:

Migraine Triggers: Educate the patient about potential triggers such as stress, irregular sleep, and alcohol consumption.

Medication Use: Shed light on the proper use of diverse medications, from short-acting to long-lasting, along with possible hazards and potential interactions.

Lifestyle Modifications: Highlighting the crucial role that a stable sleep schedule, adept stress management techniques, and a well-balanced diet and exercise habit play in maintaining optimal wellbeing.

Headache Diary: Encourage the patient to log each migraine occurrence, detailing its frequency, duration, and likely contributing factors.

The need for regular check-ups to monitor the condition.


Within 4-6 weeks, the patient should make an appointment to see their doctor to review the treatment plan’s impact. While this visit, the patient’s development will be assessed, and according to the reaction to therapy, any required corrections to prescriptions or treatment methods may be made (Evan et al., 2020). Based on the patient’s improvement, subsequent appointments may be set up at a later time.

In conclusion, the comprehensive plan created for the male patient emphasizes the value of a holistic approach to migraine management. The review of current medical research along with a detailed examination of the patient’s signs has enabled the creation of a customized therapy approach. Accurate diagnosis is facilitated through proper identification, followed by tailored medical and non-medical treatments catered to the individual’s specialized requirements. Additionally, there is a pressing need for patient instruction, punctual appointments, and potential referrals to specialists to maintain continued care and enhance overall quality of life. Developing an extensive knowledge base regarding migraine biology and its consequences enables healthcare professionals to optimize patient results and contribute meaningfully to the ongoing progression of migraine management.


Bae, J. Y., Sung, H. K., Kwon, N. Y., Go, H. Y., Kim, T. J., Shin, S. M., & Lee, S. (2021). Cognitive behavioural therapy for migraine headache: a systematic review and meta-analysis. Medicine, 58(1), 44.

Evans, R. W., Burch, R. C., Frishberg, B. M., Marmura, M. J., Mechtler, L. L., Silberstein, S. D., & Turner, D. P. (2020). Neuroimaging for migraine: the American Headache Society systematic review and evidence‐based guideline. Headache: The Journal of Head and Face Pain, 60(2), 318-336.


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