What should the initial history and physical examination include?

          This initial history and physical would include the patient’s chief complaint, HPI, ROS, and a physical exam. From the scenario provided:

          CC: New onset headaches.

          HPI: A 32-year-old female presents to the clinic with a new onset of intermittent headaches. Increase stress in life with a new job at a law firm. Headaches lasting 4 hours are rated as moderate to severe with a pulsation quality. Over the last 2 months had to leave work 5 times causing an increase in worry and the stress of possibly losing her job. With the onset of a headache, she has photophobia and nausea. Headaches are relieved by ibuprofen, lying down in a dark room, sleeping, and using cold compresses.

          ROS: negative other than what is stated in HPI.

          Physical exam: this would include objective findings with vital signs, general, HEENT exam, cardiovascular (palpate temporal arteries), neck (touch chin to chest-meninges), and palpation of the cervical spine for tenderness, respiratory, abdominal, and neurological assessment (symmetry on motor, sensory, reflex, and coordination tests) (Fenstermacher & Hudson, 2019).

         Other pertinent histories to be included would be the location of the headaches, the onset, type of pain (aching, throbbing, burning, pressing), radiation of pain, and associated symptoms such as an aura, fever, sinus pain, nausea/vomiting, neurological symptoms such tinnitus, ptosis, ataxia, photophobia or diplopia, timing of pain (how long it lasted), continuous or intermittent, triggers of pain such as activity, stress, postural, food items like caffeine, alcohol, or chocolate, alleviating factors such as medications, dark room, lying flat, quiet room, intensity of pain via pain scale, past medication history personal life and life stressors. Also, include a history of her menstruation and headache onset compared to her menstrual cycles.

Would you order diagnostic tests on Gina? Provide your rationale for why or why not.

          Diagnostics would be mostly by clinical manifestations unless this patient had a thunderclap headache (worst headache of their life), a new onset migraine headache in age over 50-55 years, a sudden onset headache, and any abnormal neurological exam. Other not-to-be-missed symptoms that will require diagnostics include if headache presents with a fever, vomiting, and or nuchal rigidity which would require immediate transfer to the Emergency Department. These presentations would most likely require a brain MRI, head CT, and or a lumbar puncture depending on their presentation. Another diagnostic to consider if her presentation wasn’t so classic would be CBC to rule in or out anemia or dehydration, TSH and T4 to rule in or out thyroid dysregulation, UA to rule in or out UTI, and ESR/CRP to rule in or out temporal arteritis.

          This patient would not require diagnostic due to her clinical manifestation of a classic migraine headache presentation with increased life stressors, headaches lasting 4 or more hours in length, headaches severe enough to miss work, during the episodic headache presenting with photophobia and nausea. Relief of headache with sleep, dark quiet room, cold compresses, and OTC ibuprofen.

What are the differential diagnoses for this patient?

          Differential diagnoses for this patient would be migraine headache, menstrual headache, and sinus headache.

What is the most likely diagnosis for this patient? Explain your answer.

          The most likely diagnosis for this patient would be migraine headache due to the presenting symptoms of starting before the age of 50, female gender, lasting 4 or more hours, and having at least 5 of the criteria of a pulsating, worsened by activity, nausea, photophobia and phonophobia and the H&P does reflex and underlying organic disease.

What are the first-line initial treatment recommendations for the management of this disorder? Provide pharmacological (with full prescription details) and nonpharmacological treatment options.

          First-line treatment recommendations for migraine headaches include OTC Naproxen 500mg orally bid prn pain, Excedrin migraine 2 tablets orally every 4-6 hours prn pain, and acetaminophen 1000mg orally every 6 hours as needed pain. Take this medication with the onset of the headache.

          Other first-line treatment recommendations include sumatriptan (Imitrex) 6 mg SQ or 50 to 100 mg PO or nasal spray, and for preventative take propranolol 20 mg orally bid and titrate to 40-160mg every day.

What patient education should you discuss with Gina?

          Education should include keeping a journal of triggers and avoiding them once established. Common triggers include caffeine, chocolate, wine, alcohol, flashing lights or bright lights, strong perfumes, or scents, and avoiding stressors. Other lifestyle measures to consider include getting plenty of sleep with good sleep routines, regular meal schedules, regular exercises, and plenty of hydration.

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