26-Year-Old Female with Frequent Severe Headaches Case Week #9:i-Human, Exams of Nursing

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i-Human Case Week #9: 26-Year-Old Female

with Frequent Severe Headaches

Case Details:

 Mode: Learning Mode (with feedback after each section and final feedback at the end)  Attempts: 1 permitted  Grading Rubric: o History: 40% o Physical Exam: 40% o Plan: 20% (faculty scored)

👩 Patient Info:

 Age: 26 years old  Height: 5'6" (168 cm)  Weight: 122 lbs (55.5 kg)  Reason for Visit: More frequent severe headaches  Setting: Outpatient clinic

 Any history of head trauma or accidents?

 Medications :

 Is she on any regular medications, including birth control, antidepressants, or over-the-counter pain relievers (e.g., ibuprofen, acetaminophen)?  Does she overuse pain medication (rebound headaches)?

 Family History :

 Any family members with a history of migraines, vascular conditions (like aneurysms), or neurological disorders?  History of genetic disorders?

 Social and Lifestyle Factors :

 What’s her stress level or work environment like?  Any sleep disturbances or recent changes in sleep patterns?  Diet, exercise, caffeine consumption, or alcohol use?  Does she have a history of anxiety, depression, or other mood disorders?

1. General Appearance:

 Alertness and Orientation : Is the patient fully awake and oriented to time, place, and person?  Level of distress : Is the patient in significant pain or discomfort during the exam? A patient in severe pain might have a tense posture, be grimacing, or appear distracted.  Facial Expression : Is the patient squinting or holding her head, which might suggest photophobia or severe discomfort from the headache?

2. Vital Signs:

 Blood pressure : Check for hypertension (could be secondary to another condition, such as a secondary cause of headache).  Pulse and Temperature : Are there any signs of infection (e.g., fever) or a systemic condition contributing to the headache? A fever, for example, could suggest meningitis, sinusitis, or a systemic infection.  Respiratory rate : Any signs of tachypnea or irregular breathing that might suggest respiratory distress or metabolic issues?

3. Head and Neck Exam:

 Inspection of the scalp : Look for any signs of injury, tenderness, or infections (e.g., signs of scalp or hair disorders, tender points).  Palpation of the head and neck : o Tenderness on palpation of the temples (suggesting temporal arteritis) or occipital tenderness (suggesting tension-type headaches). o Neck stiffness : Is there any stiffness in the neck (could suggest meningitis or other conditions)?  Sinus palpation : Pressing on the frontal and maxillary sinuses to see if this exacerbates the pain could suggest sinusitis.  Temporomandibular joint (TMJ) palpation : Is there pain or clicking that might suggest TMJ dysfunction as a potential cause for the headaches?

4. Neurological Exam:

o Nuchal rigidity : Stiff neck that resists movement could indicate meningitis or subarachnoid hemorrhage.

5. Musculoskeletal Exam:

 Palpation of the cervical spine : Check for signs of muscle tension or trigger points, which could suggest tension-type headaches or cervical spine dysfunction.  Range of Motion (ROM) : Assess for any limitations in head and neck movement, which could indicate musculoskeletal causes of headache.

6. Additional Exams (if indicated):

 Skin exam : Look for any signs of rashes, lesions, or other dermatologic findings that might suggest an infectious cause (e.g., herpes zoster).  Chest auscultation : If there's concern for a systemic cause (e.g., infection or blood pressure-related issues), listen for any abnormal lung sounds.  Abdominal exam : To rule out any signs of systemic infection or other causes of headache.

Red Flags to Look for During the Exam:

 Neurological deficits (e.g., weakness, numbness, vision loss) could suggest a more serious condition, like a stroke, brain tumor, or intracranial hemorrhage.  Papilledema or other signs of increased intracranial pressure.  Fever or signs of systemic infection (e.g., meningitis).

 Changes in the pattern or nature of headaches (e.g., a new type of headache in a patient who has had a previous history of migraines).  Systemic signs of a vascular event , like a carotid bruit or signs of stroke.

1. Differential Diagnosis:

You’ll want to consider a broad differential diagnosis, and from the patient’s history and physical exam, you'll narrow it down. Some common causes of frequent severe headaches in a young female might include:

Primary Headache Disorders:

 Migraine : Most common in women of reproductive age. Often associated with: o Pulsatile, unilateral pain o Nausea/vomiting o Photophobia and phonophobia o Aura (in some cases) o May be triggered by stress, diet, lack of sleep, or hormonal fluctuations (e.g., menstruation or oral contraceptive use).  Tension-Type Headache : Often described as a "band-like" tightness around the head. Characterized by: o Dull, non-pulsatile pain o No nausea or vomiting, but some may report mild photophobia. o Often related to stress or poor posture.  Cluster Headaches : Rare but very severe, typically unilateral, and often associated with autonomic symptoms

o Increased Intracranial Pressure (ICP) : Headache that is worse in the morning, associated with nausea/vomiting, and potentially signs of papilledema.  Meningitis/Encephalitis : If there are signs of fever, neck stiffness, or photophobia. o Headache with fever, stiff neck, altered mental status.  Temporal Arteritis : Rare in a 26-year-old but still worth considering if there is tenderness over the temporal arteries or visual disturbances.  Hypertension : Severe, uncontrolled hypertension can cause headaches, often with symptoms like blurred vision, chest pain, and dizziness.  Trigeminal Neuralgia : Severe, stabbing pain in the face, typically along the distribution of the trigeminal nerve.

2. Red Flags:

Some key "red flags" that you should consider if they appear in history or physical exam:

 Sudden onset of the headache (e.g., "thunderclap" headache) that is the worst headache ever experienced.  Neurological deficits (e.g., weakness, numbness, altered speech, or vision changes).  Progressively worsening headache pattern or new onset in adulthood.  Fever, neck stiffness, or photophobia suggesting an infection like meningitis.  Changes in mental status or behavior, which could point to increased intracranial pressure, a mass, or encephalitis.

 Morning headaches or headaches that wake the patient from sleep, which could indicate increased intracranial pressure or a space-occupying lesion.

3. Plan (Management):

Based on the findings from the assessment, you would outline an initial management plan:

Initial Work-Up:

1. Imaging : o MRI or CT of the Brain : If there are any concerns for intracranial pathology (e.g., mass effect, hemorrhage, or hydrocephalus), particularly if red flags are present (neurological deficits, sudden onset, worsening headaches). o If there's a concern for sinusitis, a sinus CT or nasal endoscopy might be appropriate.
2. Labs : o Complete Blood Count (CBC) : To check for signs of infection or inflammation (e.g., elevated white blood cell count suggesting infection or temporal arteritis). o Electrolytes, renal function, and liver function tests : If there's concern for systemic issues contributing to headache (e.g., dehydration, electrolyte imbalance). o ESR and CRP : Elevated in cases of temporal arteritis, systemic inflammation, or infection. o Pregnancy test : If there’s any chance the patient might be pregnant (as some medications, such as NSAIDs, are contraindicated during pregnancy).

topiramate, amitriptyline, or other medications (e.g., for migraines or tension-type headaches).  Lifestyle modifications : Educate on headache triggers (stress, lack of sleep, dietary factors) and lifestyle changes (e.g., sleep hygiene, caffeine management, regular exercise).

Patient Education:

 Headache diary : Encourage the patient to keep a headache diary to track potential triggers, frequency, and severity.  Caffeine reduction : If caffeine withdrawal is a trigger, suggest a gradual reduction.  Stress management techniques : Including mindfulness, relaxation exercises, or cognitive-behavioral therapy (CBT) if stress is a major factor.

4. Follow-Up:

 Schedule follow-up visits to reassess the effectiveness of the treatment and adjust the management plan if necessary.  Re-evaluate if there are no improvements or if new symptoms develop, suggesting a more serious underlying cause.

🠀 Diagnostic Tests for Frequent Severe Headaches

🠀 1. Neuroimaging

 MRI of the Brain (with and without contrast) o Best for detecting tumors, vascular malformations, demyelinating diseases, etc.  CT Head (non-contrast)

o Faster; good for acute bleeds or trauma. o Used if MRI is contraindicated or unavailable.

🠀 2. Laboratory Tests

 CBC (Complete Blood Count) o To check for infection or anemia.  ESR/CRP o For inflammation; especially if temporal arteritis is suspected.  Thyroid Function Tests (TSH, Free T4) o To rule out hypothyroidism as a contributor.  Electrolytes, BUN, Creatinine o Evaluate metabolic causes (e.g., hyponatremia).  Pregnancy Test (if applicable) o Headache workup differs during pregnancy.

🠀 3. Lumbar Puncture (if indicated)

 Indicated if: o Suspected meningitis , subarachnoid hemorrhage (with normal CT), or idiopathic intracranial hypertension.  Opening pressure and CSF analysis (cells, protein, glucose, cultures) provide diagnostic clues.

🔬 4. Specialized Tests (if clinically indicated)

 EEG – if seizures or atypical symptoms are present.  Ophthalmologic exam / Fundoscopy – to assess for papilledema.  Visual field testing – to assess optic nerve involvement (e.g., in pseudotumor cerebri).

Feature Migraine Tension-Type Cluster Headache

Room rocking helps)

Aura (visual/sensory)

Common (especially visual)

Absent Absent

Sleep impact

Often worsens with lack of sleep

Related to tension/fatigue

Often wakes patient from sleep

Gender Predilection

More common in females

Equal between genders

More common in males

Frequency

Variable (episodic or chronic)

Episodic or chronic

Attacks occur in “clusters” (e.g., 1–8/day for weeks)

🔍 Clinical Clues

 Migraine if: unilateral, pulsating, with nausea and light/sound sensitivity, possibly with aura  Tension-type if: bilateral, pressure-like, mild intensity, no associated features  Cluster if: severe pain behind one eye, occurring at the same time daily, with tearing and nasal congestion

🠀 Final Diagnosis: Migraine Without Aura

📋 Rationale:

 Age and Gender : Migraine is most prevalent in young adult women.  Headache Characteristics : o Likely unilateral , throbbing in nature o Lasts several hours to days o May be worsened by activity  Associated Symptoms : o Often includes nausea , photophobia , phonophobia o Aura may be absent in many cases (common in "migraine without aura")  Frequency Increase : o Migraines can become more frequent due to triggers (stress, sleep disruption, hormonal changes, etc.)

🠀 Less Likely Diagnoses:

 Tension-Type Headache : Usually milder, bilateral, and lacks nausea/photophobia.  Cluster Headache : Shorter duration, more common in males, and features autonomic symptoms (tearing, ptosis).  Medication Overuse Headache : Only likely if there’s a history of daily analgesic use.  Secondary Causes (e.g., tumor, IIH) : Less likely without neurological signs or visual changes

🠀🠀 Migraine Without Aura – Treatment Plan

🠀 1. Non-Pharmacologic Management

 Helps with nausea and improves absorption of oral meds

🛡 🠀 3. Preventive (Prophylactic) Therapy

Consider if:

 ≥4 headache days/month or severe disability  Poor response to abortive meds  First-line options: o Beta-blockers (e.g., Propranolol) o Tricyclic antidepressants (e.g., Amitriptyline) o Topiramate or Valproate (antiepileptics)  Menstrual-related migraines : Consider hormonal therapy or short-term triptan use during high-risk days

🠀 4. Follow-Up & Monitoring

 Follow-up visit in 4–6 weeks to assess response to treatment and side effects  Review headache diary  Adjust therapy as needed (especially if frequency increases)

🠀 5. Patient Education / Red Flags

 Educate on medication overuse headache risk (limit acute meds to <10 days/month for triptans, <15 for NSAIDs)

 Warn about red flag symptoms : o Sudden onset “thunderclap” headache o New neurological deficits o Headache with fever, neck stiffness, or systemic illness