What should the initial history and physical examination include?

The provider should inquire if the patient has a family history of headaches. Also, determining when exactly the headaches occur, how often, if there is anything that makes the headaches worse besides light? If anything helps besides Ibuprofen and a cold compress? It is also important to determine where exactly the pain is on/in her head. Does she take any medication to help with her recent increase in stress? What other medication is she on, could an adverse of any medication be headaches? Do the headaches come on abruptly or get increasingly worse over time? Is aura present with the headaches? How long do they last? What is her sleep and exercise habits like? Do her headaches occur when she is on her menstrual cycle? Does the pain radiate elsewhere? Does she experience loss of balance or function?

Physical exam- A full assessment including a full set of vitals, a neurological assessment looking for any focal deficits or changes in baseline, cranial nerve function testing, motor/sensory function testing, and examination of the head/neck.

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

Though it is not necessary for a CT or MRI to be performed, I believe I would order imaging to ensure there are not obvious causes such as a tumor or ischemic areas in the brain. Imaging should be ordered if the headaches are atypical, have changed, or have created personality changes, seizures, or focal neurological symptoms (Dunphy et al. 2022). Though this patient does not have any focal symptoms, personality changes, or seizures, these headaches are new and atypical for her. I believe a CT/MRI may be warranted.

What are the differential diagnoses for this patient?

Differential diagnoses include a brain tumor (cancerous vs benign), ICH, CVA, TIA, meningitis, migraines with or without aura, cluster headaches, tension headaches, or an infection in the brain or systemically (Shen & Qi, 2022).

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

It is likely that this patient is suffering from migraine headaches. Migraine headaches typically are a throbbing/dull time of pain, associated findings including sensitivity to light, nausea, and a headache that lasts a significant amount of time (Dunphy et al., 2022). This patient has all of these symptoms. Additionally, factors that help to alleviate the pain such as a cold compress and sleeping in a dark room are consistent with migraine headache relief options.

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

Since the patient has already utilized Ibuprofen and has found little relief, I believe a Triptan should be prescribed as an abortive treatment option for when she is experiencing a migraine. Sumatriptan 25mg PO, at onset of headache, may repeat dose up to 100mg Q2H, #30, no refills (Kang, 2021).

I would not begin the patient on a prophylactic medication at this time due to her not experiencing migraines for a long period of time. It would be my hopes that with the abortive medication and nonpharmacological treatment options that her migraines should improve. Nonpharmacological treatment includes applying lavender oil to her temples, drink 1-2 cups of coffee at the onset of a migraine, eat foods high in magnesium or begin a magnesium supplement, avoid trigger foods, utilize acupuncture/acupressure, massage, and drinking green tea (Dunphy et al., 2022).

What patient education should you discuss with Gina?

Gina should be educated on the need to keep a diary of her migraines including onset, duration, treatment utilized, and if anything triggered the migraine. This will help the provider direct the next course of treatment. In addition to this, education on avoiding trigger foods such as red wines, foods high in nitrates, chocolate is important. She should also be educated on stress-management techniques as it is likely her migraines are triggered by her increase in stress. Education on side effects of Sumatriptan include nausea, dizziness, chest/neck tightness, and paresthesia (Dunphy et al., 2022). It is important to educate the patient that it may take time to find the perfect medication combo to help lower the frequency of migraines and that follow-up with the provider is to be expected.

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