Topic: Case and Discussion: Headache
A 35-year-old woman comes to your office to discuss her “bad headaches,” which started after having her first child 2 years ago. The headaches sometimes awaken her from sleep and at times can be disabling and occasionally require her to take Tylenol and rest in a dark room. Sometimes she vomits during an attack. Over the past 6 months, her headaches have become more severe and frequent, prompting her visit today.
- What additional questions would you ask to learn more about her headaches?
- How do you classify headaches?
- How can you determine if this is an old headache or a new headache/s? Is this a chronic or episodic condition?
- Can you make a definite diagnosis through an open-ended history followed by focused questions?
- How can you use the patient history to distinguish between benign headaches and serious ones that require urgent attention?
- What diagnostic tests do you want to include to help you with your diagnosis?
- Create a differential diagnosis flow sheet for this patient for this patient and include the diagnostics related to the differentials.
Use at least 3 references
Expert Solution Preview
Introduction:
Headaches can be a distressing and disabling condition for many patients. As a medical professor, it is essential to educate medical college students on how to diagnose and treat the various types of headaches. In this case study, we will discuss a 35-year-old woman presenting with a history of severe headaches. We will cover additional questions to ask and how to distinguish between benign and serious headaches, among other topics.
1. What additional questions would you ask to learn more about her headaches?
To learn more about the patient’s headache, additional questions to ask include the location, quality, severity, and duration of the headache. Other important questions to ask include any associated symptoms such as nausea, vomiting, photophobia, or phonophobia. Medical students should also consider asking about the frequency and timing of headaches, any potential triggers, and the patient’s medical history.
2. How do you classify headaches?
Headaches can be classified as primary, secondary, or cranial neuralgias, and facial pain. Primary headaches include migraines, tension-type, and cluster headaches. Secondary headaches result from underlying conditions such as sinusitis, meningitis, and brain tumors. Cranial neuralgias and facial pain can include conditions like trigeminal neuralgia and atypical facial pain.
3. How can you determine if this is an old headache or a new headache/s? Is this a chronic or episodic condition?
To determine if the headache is a new or old headache and to classify whether it’s chronic or episodic, one should ask about changes in the frequency and severity of headaches. Medical students should also ask about any prior history of headaches and any treatments the patient may have had for their condition.
4. Can you make a definite diagnosis through an open-ended history followed by focused questions?
While a definite diagnosis may not always be possible through an open-ended history followed by focused questions, it is essential for medical students to gather as much information as possible from the patient. Understanding the characteristics of the headache and associated symptoms will help narrow the differential diagnosis.
5. How can you use the patient history to distinguish between benign headaches and serious ones that require urgent attention?
A thorough patient history can help distinguish between benign and serious headaches. Red flags to look out for include the sudden onset of the headache, severe pain, neck stiffness, fever, seizures, focal neurological deficits, and changes in mental status. If any of these are present, medical students should consider urgent neuroimaging and other diagnostic tests.
6. What diagnostic tests do you want to include to help you with your diagnosis?
Diagnostic tests can include neuroimaging such as computed tomography (CT) or magnetic resonance imaging (MRI) of the brain, blood tests, and lumbar puncture to rule out meningitis or intracranial bleeding. Medical students must only order testing that is clinically indicated to avoid unnecessary testing and prevent harm to the patient.
7. Create a differential diagnosis flow sheet for this patient for this patient and include the diagnostics related to the differentials.
Possible differentials could include migraine headache, tension-type headache, sinusitis, brain tumor, or intracranial hypotension. For migraine headache, diagnostic tests can include an electroencephalogram (EEG) or blood tests to check for inflammatory markers. For sinusitis or intracranial hypotension, a CT or MRI scan would be necessary to confirm or rule out the diagnosis. In the case of a brain tumor, a CT or MRI scan would be necessary to visualize and identify any abnormalities. Medical students should consider each differential and order diagnostic tests appropriately.
References:
1. Headache Classification Committee of the International Headache Society (IHS) The International Classification of Headache Disorders, 3rd edition. Cephalalgia. 2018;38(1):1-211.
2. Goadsby P, Raskin N. Headache. N Engl J Med. 2014;370(4):389-398.
3. Garza I, Schwedt T, Robertson C. Headache and Facial Pain. Am J Med. 2018;131(1):17-24.
