Frequent Migraines Asking for Something to Prevent Them — Free SCA Practice Case

Character Overview: You are Leyla Demir, a 29 year old self employed wedding photographer. You work for yourself, shooting weddings at weekends and editing the photos on your laptop during the week. You live with your fiancé Joe, a plumber, in a rented flat, and you are getting married in about five months. You have had migraines since you were about 16. A GP confirmed them two years ago and started you on sumatriptan. Since your diary filled up about six months ago they have gone from one or two a month to about six days a month, and you have had to cancel or hand on shoots, so some couples have booked other photographers. Your best friend Ellie takes a tablet called topiramate to prevent her migraines and says it has changed her life, so you have booked this appointment hoping to start the same tablet today. You are friendly and practical but sound tired and flat, and your voice tightens when work comes up.

Opening Sentence: "Thanks for seeing me. My migraines have got so much worse lately, about six days a month now, and I've had to cancel some jobs. My friend's on a tablet called topiramate to stop hers and it's been amazing for her, so I was hoping I could go on that."

History if Asked (Data Gathering Phase)

• ●How often: "For about the last six months it's been about six days a month. Before that it was one or two a month at most."
• ●What they are like: "Same kind of headache I've always had, just much more often. One side, usually the right, behind my eye, and it throbs. Eight out of ten when it's bad. I feel really sick, sometimes sick once, and I can't stand light or noise, so I lie in a dark room with a cold flannel."
• ●How long they last and how they build: "Most of the day, sometimes into the next morning, and I'm wiped out the day after. They build up over an hour, usually in the afternoon while I'm editing, sometimes on a Sunday when I've had a lie in and no coffee."
• ●Before the headache (if asked about warning signs, flashing lights, zigzags, numbness or speech problems): "No, nothing like that. I just feel tired and yawny for a bit, then the headache comes."
• ●What she takes for them (if asked about medicines or painkillers): "I wait until it's really bad before taking the sumatriptan because I only get six a month and I'm scared of running out. Taken that late it works maybe half the time. If it comes back I take a second a couple of hours later. I've never tried anything to prevent them."
• ●How many days she takes them (if asked): "The sumatriptan on five or six days a month, with two ibuprofen on those days. Paracetamol doesn't touch it. Between migraines I get no headaches, so I take nothing else."
• ●What sets them off (if asked): "Since my diary filled up I skip lunch most days, I'm on four or five coffees a day, and I'm lucky if I get six hours' sleep because I'm editing late. Red wine sets one off sometimes, so I stick to white now."
• ●Periods (if asked): "They're regular, every 28 days or so. My last one started about two weeks ago. Maybe one of the migraines each month is around my period, but the rest are all over the place."

Ideas, Concerns, Expectations

Gating note: Leyla does not raise any of the following herself. Each part comes out only when the doctor asks what she thinks is going on, what is worrying her, or what she was hoping for.

• ●Ideas: She thinks being so busy and sleeping badly have made them worse, maybe her hormones, and assumes Ellie's tablet will work for her. "I think it's being so busy, honestly, and not sleeping. But Ellie had exactly the same and that tablet sorted her out, so I figured it would work for me."
• ●Concerns: Her main worry is her business. She has had to cancel or hand on four shoots in three months and two couples have already booked someone else, and she fears that if she lets one more couple down word will get round and bookings will dry up. She is self employed, so she is not paid when she cannot work. "I've built this up on my own and now I'm the photographer who might not turn up. If I'm not shooting I'm not earning." If the doctor explores further, a second, quieter worry comes out: "And when we try for a baby, my mum says hers were awful when she was pregnant with me. I'm dreading being stuck with them and not being able to take anything."
• ●Expectations: She came hoping to leave with a prescription for topiramate today. "I was hoping I could just start the same tablet as Ellie today, to be honest."

If Asked: Medical History and Medications

Gating note: Leyla answers each of these plainly when the doctor asks about it.

• ●Other health problems: "Nothing else really. I've never had asthma or a wheezy chest, heart problems or fainting, and my fingers are fine in the cold. The pharmacist said my blood pressure was fine."
• ●Mood: "I'm fed up and stressed with work, but I'm not depressed, and I've never had thoughts of harming myself."
• ●Sleep: "Not great. Six hours is a good night."
• ●Sumatriptan and other medicines: "It works well if I take it early, but I've been saving them. Otherwise just supermarket ibuprofen. Nothing new, no allergies."
• ●The pill: "I was on the combined pill for years and came off it about 18 months ago because I wanted a break from hormones. I didn't notice it changed the migraines. I use nothing now. Joe's careful, if you know what I mean."
• ●Baby plans: "We're getting married in about five months and want to start trying straight after. If it happened sooner we'd be happy, honestly. It just isn't the plan."
• ●Pregnancy now and folic acid: "I don't think so. My period came two weeks ago and was normal. I'm not taking folic acid."
• ●Topiramate and Ellie: "Ellie's my age. She's been on it about a year and her migraines have nearly gone. Her fingers went tingly at first. She has to sign some form at her yearly review, but I didn't ask what it was about."
• ●Practical questions (if the relevant topic is raised): She asks what to write in a diary and whether she can have enough tablets to take the triptan early. She cannot check her own pulse or blood pressure on camera and offers to see the nurse. Her mum's migraines stopped after her menopause. If offered help for work: "That would really help. Couples want to know I'll be there on the day, and I need something I can tell them."

Social History and Lifestyle Impact

• ●Work: Self employed wedding photographer, working alone from a spare room at home. Shoots most weekends and spends hours on screens editing during the week, often late into the evening.
• ●Lifestyle impact: "I've had to cancel or hand on four shoots in the last three months, and two couples have gone to someone else. Last month I cancelled my wedding dress fitting because I was lying in a dark room. Joe's been brilliant, but I hate how many weekends it's eating."
• ●Daily life: "I go running on Saturdays when I haven't got a wedding and I'm not wiped out. Four or five coffees through the day, and I skip lunch because I'm editing or on a shoot. A few glasses of white wine at the weekend. I've never smoked." Early starts on shoot days. Joe is supportive.

If Asked: Associated Symptoms

Gating note: Answers are brief. All of the following are negative: a sudden explosive or worst ever headache (they always build up over an hour), headache worse lying down or on coughing or straining, waking at night with headache, morning vomiting, weakness, numbness, speech trouble, loss or double vision, fever, stiff neck, rash, head injury, ringing in the ears, weight change and anything new in her health or medicines.

Responses to Management (The Negotiation Phase)

• ●If the doctor explains that topiramate is not suitable because of the risks if she became pregnant:
  • ●Reaction: Surprised, a little deflated, then curious. "Ellie never said anything about babies. So is she alright on it?" Once told Ellie probably uses reliable contraception and has yearly checks: "That'll be the form she signs. So what can I have instead?"
• ●If the doctor offers topiramate on condition that she has a coil or an implant fitted, or suggests contraception more generally:
  • ●Reaction: Open but clear. "I came off the pill for a break from hormones, and I don't want a coil or anything put in when we're trying after the wedding. I suppose we could use condoms until then." If the combined pill is raised she asks whether it is safe with migraines.
• ●If the doctor suggests propranolol, amitriptyline or a choice between the two:
  • ●Reaction: Puzzled at first. "Isn't propranolol a blood pressure tablet? Mine's fine." Wary of amitriptyline: "Isn't that an antidepressant?" Once explained: "Will it slow me down when I'm running? Make me groggy on a shoot day, when I'm driving and carrying kit? How long before I know it's working?" She leans towards whichever fits her early starts and her running.
• ●If the doctor explains how long she would need to take it, or what happens if she becomes pregnant on it:
  • ●Reaction: "So it's not forever? And I'd have to come off it when we start trying? What if they come back worse?" She is reassured by what usually happens to migraines in pregnancy and by a plan. If folic acid is recommended: "Now, even though we're not properly trying?" She accepts once the reason is explained.
• ●If the doctor suggests a brain scan or referral to a specialist before starting anything:
  • ●Reaction: Anxious. "Is that because you think it's something worse?" She settles if told why a scan is or is not needed. About referral: "How long would that take? I've got a wedding booked in two weeks." She accepts if something helps meanwhile.
• ●If the doctor gives vague safety netting such as "come back if it gets worse":
  • ●Reaction: "Worse how? They're already pretty bad. What would actually mean I need to be seen quickly?"