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Internal Medicine

Training Level

Resident PGY 2


Henry Ford Allegiance Health


Background: Headaches have been extensively reported in Antiphospholipid syndrome (APS)/Antiphospholipid antibodies (aPL)-positive patients. Headaches associated with APS is often untreatable, poorly responding to analgesics or narcotics and occurs for years before the diagnosis of APS. Conventional imaging studies are usually negative. Many therapeutic agents/strategies such as hydroxychloroquine, B cell inhibition, complement inhibition, statins, and peptide therapy have been proposed to manage thrombotic APS. Nonetheless, Heparin followed by Long-term anticoagulation with warfarin remains the cornerstone of treatment. Case Report: A 36-year-old Caucasian female with past medical history significant for Tumid Lupus Erythematosus treated with Hydroxychloroquine, Fibromyalgia and remote history of Irritable Bowel Syndrome, no history of Thrombosis, miscarriages, fetal death or preeclampsia. She presented with severe headaches, 8/10 intensity for the last 4 years, reported as stabbing pain, occasionally localizing to right side. Pt had undergone extensive workup by Neurology as well as Rheumatology including a normal Lumbar Puncture and multiple normal MRI brain. Blood work showed Lupus Anticoagulant positivity with a higher than normal Dilute Russel Viper Venom Test (dRVVT). The rheumatologist started the patient on Warfarin Therapy for Headaches associated with APS with INR goal of 2-3, which significantly relieved the symptoms. Later, warfarin was discontinued by the neurologist, who the patient saw for a follow up, resulting in worsening of the headaches. The headaches resolved again on restarting the Warfarin Therapy. Learning Points: Headaches and migraine in particular are common in APS and aPL-positive patients.The pathogenesis of APS headaches is unclear, but it could be related to platelet dysfunction. APS patients with severe refractory migraine show very good response to anticoagulation therapy.

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Warfarin for Headaches?!