Frequent Severe Headaches in a 26-Year-Old: Comprehensive Evaluation and Management, Exams of Nursing

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Comprehensive

Comprehensive



Age : 26 years old



Gender : Female



Height : 5'6" (168 cm)



Weight : 122.0 lbs (55.5 kg)



Reason for encounter : Frequent

severe headaches



Location : Outpatient clinic

Comprehensive

Comprehensive

The reason for encounter for this patient is

frequent severe headaches.

Common Causes of Severe Headaches

1.Primary Headaches (no underlying disease)

o

Migraine :

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

Often unilateral, throbbing pain.



May be associated with nausea,

vomiting, and sensitivity to light

(photophobia) or sound

(phonophobia).



Can last from 4 to 72 hours.



May have an aura (visual

disturbances, sensory changes) before

the onset.

o

Tension Headaches :



Band-like pain, often described as a

tightness or pressure around the head.



Less likely to cause severe disability

compared to migraines.



Usually bilateral and not associated

with nausea or vomiting.

o

Cluster Headaches :



Intense, excruciating pain, usually

around one eye or temple.



Often occurs in clusters, with

multiple

attacks in a short period (days to

weeks), followed by periods of

remission.



Associated symptoms: tearing of the

eyes, nasal congestion, and facial

sweating.

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2.Secondary Headaches (caused by

underlying issues)

o

Sinusitis :



Associated with sinus pressure and

congestion, pain in the forehead,

cheeks, or around the eyes.

o

Hypertension :



Severe headaches can occur with very

high blood pressure.

o

Medication Overuse :



Rebound headaches from overuse of

pain medications like NSAIDs,

acetaminophen, or triptans.

o

Trauma :



Head injury or whiplash can lead to

post-traumatic headaches.

o

Cervicogenic Headache :



Originates from the neck but is felt in

the head, often due to problems with

the cervical spine.

o

Brain Tumor or Space-Occupying

Lesions :



Rare, but can cause progressive

headaches, often worse in the morning

or with changes in position.



Associated with neurological deficits,

vision changes, or cognitive decline.

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3.Other Potential Causes :

o

Hormonal Factors :



Women, especially in reproductive

age, may experience headaches related

to hormonal fluctuations (e.g.,

menstrual migraines).

o

Infections :



Meningitis or encephalitis can present

with severe headaches, but usually

accompanied by fever, stiff neck, or

altered mental status.

o

Temporal Arteritis :



Typically occurs in older adults, but a

severe, persistent headache along with

scalp tenderness and jaw pain while

chewing can be signs.

o

Subarachnoid Hemorrhage :



A sudden, severe "thunderclap"

headache that may indicate a rupture

of an aneurysm. This is an emergency.

Diagnostic Approach

1. History Taking :

o

Onset, duration, frequency, and character

of the headache (e.g., throbbing, pressure).

o

Location (unilateral vs bilateral).

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o

Associated symptoms: nausea, vomiting,

vision changes, aura, neck stiffness, fever.

o

Aggravating/alleviating factors (e.g.,

worse with movement, better with rest).

o

Triggers (e.g., stress, foods, menstrual

cycle).

o

Use of medications, including over-the-

counter pain relief.

o

Family history of headaches or

migraines.

o

Recent head trauma or infections.

2.Physical Exam :

o

General Examination : Look for signs of

systemic illness (fever, weight loss, etc.).

o

Neurological Examination : Assess

cranial nerves, motor and sensory

function, reflexes, and mental status.

o

Palpation : Check for tenderness over the

sinuses, cervical spine, or scalp arteries

(for temporal arteritis).

3.Diagnostic Tests (if indicated based on

history/exam):

o

Imaging :



CT scan or MRI : To rule out

intracranial pathology like a tumor,

aneurysm, or structural abnormalities.

o

Blood Work :



CBC for signs of infection or anemia.

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

ESR or CRP for temporal arteritis in

older patients.

o

Lumbar Puncture :



To rule out meningitis or subarachnoid

hemorrhage in cases with severe

sudden onset or signs of infection.

o

Blood Pressure Measurement : To check

for hypertensive crisis.

Initial Management Options

1.For Migraine :

o

Acute treatment : NSAIDs,

acetaminophen, or triptans (sumatriptan,

rizatriptan).

o

Prophylactic treatment : Beta-blockers,

anticonvulsants (topiramate), or

antidepressants (amitriptyline).

o

Lifestyle : Avoid known triggers, maintain

regular sleep, diet, and exercise routines.

2.For Tension Headaches :

o

NSAIDs or acetaminophen.

o

Stress management, physical therapy for

posture correction.

3.For Cluster Headaches :

o

Oxygen therapy.

o

Triptans (injectable sumatriptan).

o

Preventive medications like verapamil.

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Red Flags ("Emergency") to Watch For:



"Thunderclap" headache (sudden onset,

severe).



Headache with neurological deficits (e.g.,

vision loss, weakness).



Headache with fever and neck stiffness

(meningitis).



Progressively worsening headache

over time.

1. Migraine



Key Features :

o

Unilateral throbbing or pulsating pain, but

can be bilateral.

o

Often moderate to severe intensity.

o

Associated with nausea, vomiting , and

sensitivity to light (photophobia) or sound

(phonophobia).

o

Can last from 4 to 72 hours.

o

May have an aura (visual or sensory

disturbances) before the headache starts.

o

Triggered by stress, certain foods (e.g.,

chocolate, cheese), hormonal changes

(e.g., menstruation), or lack of sleep.



Diagnostic Clues :

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o

Ask the patient if they experience any

visual disturbances or other warning signs

before the headache begins.

o

Check for a family history of migraines ,

as they often run in families.

o

Look for lifestyle or dietary triggers that

could be contributing.



Management :

o

Abortive : NSAIDs (e.g., ibuprofen),

triptans (e.g., sumatriptan), or anti-nausea

medications.

o

Preventive : If headaches are frequent,

consider beta-blockers, topiramate, or

antidepressants.

o

Lifestyle changes : Avoid known triggers,

ensure proper sleep, hydration, and stress

management.

2. Tension-Type Headache



Key Features :

o

Described as a band-like tightness or

pressure around the head.

o

Usually bilateral (on both sides of the

head).

o

Often mild to moderate in intensity.

o

No nausea or vomiting ; less likely to

have sensitivity to light or sound.

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o

Can be triggered by stress , poor posture,

or muscle tension in the neck and

shoulders.



Diagnostic Clues :

o

The patient may describe a constant, dull

pressure , like a tight band around the

forehead.

o

Check for a history of stress, anxiety, or

long hours in poor posture (e.g., desk

job).

o

Physical exam : Palpation of the neck

and

shoulder muscles may reveal tenderness or

tightness.



Management :

o

NSAIDs (e.g., ibuprofen, acetaminophen).

o

Stress management : Cognitive

behavioral therapy, relaxation techniques,

or biofeedback.

o

Physical therapy : Addressing posture,

muscle tension, and ergonomics.

3.Cluster Headache (less likely but

important to consider)



Key Features :

o

Severe, unilateral pain around one eye or

temple.

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o

Occurs in clusters (i.e., several attacks

over weeks, followed by periods of

remission).

o

Attacks often happen at the same time

each day and may last from 15 minutes to

3 hours.

o

Associated symptoms: tearing of the

eyes , runny nose , facial sweating , or

eyelid drooping.

o

Patients may feel restless during attacks,

unlike migraine patients who prefer to lie

down.



Diagnostic Clues :

o

Look for a pattern of attacks : Does the

patient experience multiple attacks within

a certain period (days to weeks)?

o

The patient may describe sharp, stabbing

pain around one eye.

o

Associated autonomic symptoms (tearing,

congestion) are key diagnostic clues.



Management :

o

Abortive : 100% oxygen therapy via face

mask or injectable triptans.

o

Preventive : Verapamil or corticosteroids

may be used to prevent future clusters.

Next Steps for Narrowing Down Diagnosis:

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

Detailed History :

o

Focus on understanding the pattern of the

headaches (how long they last, when they

occur, what triggers them).

o

Ask about associated symptoms like

nausea, photophobia, aura, or

neck/shoulder tension.

o

Check for lifestyle factors such as stress,

sleep patterns, diet, or hormonal cycles.



Physical Exam :

o

Check for tenderness in the neck,

shoulders, and head muscles.

o

Perform a neurological exam to

ensure

there are no focal deficits that could

indicate a more serious secondary cause

(e.g., tumor, infection).



Consider Diagnostic Tests if Red Flags:

o

If the patient has red flags (e.g., sudden

onset, neurological symptoms, changes in

headache pattern), imaging (CT or MRI)

or other investigations may be warranted.

Key Differentiators Among Headaches

1. Migraine :

o

Pain : Typically unilateral (one-sided),

throbbing or pulsating.

o

Associated symptoms :

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

Nausea and vomiting.



Photophobia (sensitivity to light) and

phonophobia (sensitivity to sound).



Possible aura (20-30% of migraine

patients): flashing lights, blind spots,

or tingling before the headache starts.

o

Duration : Can last from 4 to 72 hours.

o

Triggers : Certain foods (e.g., chocolate,

red wine, cheese), hormonal changes

(e.g., menstruation), stress, bright lights,

lack of sleep.

o

Behavior : The patient often wants to lie

down in a dark, quiet room.

o

Diagnostic clues : Ask if the patient has

warning signs like visual disturbances

(aura) before the headache. Also, inquire if

their headaches are worsened by routine

physical activity (e.g., climbing stairs).

2.Tension-Type Headache :

o

Pain : Usually bilateral (both sides),

described as a constant dull, pressing , or

tightening pain, like a tight band around

the forehead.

o

Associated symptoms :



Not typically associated with nausea

or vomiting.

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

No aura and no sensitivity to

light/sound (though mild sensitivity is

possible).

o

Duration : Can last from 30 minutes to

several hours , sometimes lasting days.

o

Triggers : Stress , poor posture , muscle

tension, fatigue, anxiety.

o

Behavior : Patients can typically continue

daily activities , though it might be

uncomfortable.

o

Diagnostic clues : The absence of nausea,

aura, or severe photophobia/phonophobia

helps distinguish this from migraines.

Check if the patient reports muscle tension

in the neck or back, or stress-related

headaches.

3.Cluster Headache :

o

Pain : Intense, severe pain, usually

unilateral (focused around one eye or

temple).

o

Associated symptoms :



Tearing of the eyes , nasal congestion,

facial sweating, ptosis (drooping

eyelid).



Pain is excruciating and described as

sharp or stabbing.

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o

Duration : Each episode lasts 15 minutes

to 3 hours.

o

Frequency : Occurs in clusters —multiple

attacks over several days or weeks,

followed by periods of remission.

o

Behavior : Patients are often restless ,

pacing, or rocking (unlike migraines,

where the patient prefers to lie still).

o

Diagnostic clues : The distinct pattern of

short but extremely painful attacks

happening several times a day for weeks.

Look for autonomic symptoms like tearing

or nasal congestion.

Differential Diagnosis for Secondary Causes

(Red Flags)

If the patient's history or physical exam raises

suspicion of secondary causes, consider the

following:

1.Red Flags for Serious Conditions :

o

Sudden, severe "thunderclap"

headache : Could indicate a subarachnoid

hemorrhage (ruptured aneurysm).

Immediate CT imaging is required.

o

Focal neurological signs (e.g., weakness,

vision loss, speech difficulties): May

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suggest a brain tumor, stroke, or other

intracranial pathology.

o

New onset headache in a patient with a

history of cancer or HIV : Could indicate

metastasis, infection (e.g., meningitis), or

other secondary causes.

o

Headache that is progressively

worsening over days or weeks.

o

Morning headaches, worse

with

coughing or straining : Could indicate

increased intracranial pressure (e.g.,

tumor, hydrocephalus).

o

Fever, stiff neck, altered mental status :

Could suggest meningitis or encephalitis.

2.Secondary Headache Causes to consider if

red flags are present:

o

Intracranial mass (tumor, abscess):

Progressive headaches, often worse in the

morning, with focal neurological deficits.

o

Meningitis : Severe headache with fever,

neck stiffness, and photophobia.

o

Hypertensive emergency : Headache with

dangerously high blood pressure

(>180/120), often with visual disturbances

or confusion.

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o

Sinusitis : Pressure-type headache, often

localized to the forehead or cheeks, with

sinus congestion.

Diagnostic Workup

If red flags are absent, primary headache disorders

like migraine or tension-type headache are likely.

However, if you suspect a secondary cause,

consider these diagnostic steps:

1.Imaging :

o

CT or MRI of the brain if the patient has:



New onset headaches with

neurological signs.



Sudden onset of a severe headache

("worst headache of their life").



History of trauma, cancer, or

immunosuppression.

o

CT angiography to rule out vascular

issues like aneurysm or stroke if there’s a

thunderclap headache.

2.Laboratory Tests :

o

If infection is suspected (e.g., meningitis),

a lumbar puncture to analyze

cerebrospinal fluid (CSF) for infection or

hemorrhage.

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o

Blood tests for inflammatory markers

(e.g., ESR, CRP) if giant cell arteritis

(more common in older patients) or

infection is suspected.

3.Headache Diary :

o

Ask the patient to keep a headache

diary

for a few weeks. They should

document:



Time of day and duration of

headaches.



Intensity and location of

pain.



Any associated symptoms (nausea,

aura, etc.).



Possible triggers (food, stress,

sleep

patterns).

Treatment Strategies Based on Likely

Diagnosis

1. Migraine :

o

Abortive : NSAIDs (ibuprofen), triptans

(sumatriptan, rizatriptan), and antiemetics

for nausea.

o

Prophylactic (for frequent migraines):

Beta-blockers (e.g., propranolol),

anticonvulsants (e.g., topiramate), or

tricyclic antidepressants (e.g.,

amitriptyline).

Comprehensive

o

Lifestyle changes : Identify and avoid

triggers (e.g., bright lights, stress, certain

foods), maintain regular sleep schedule.

2.Tension-Type Headache :

o

Pain relief : NSAIDs or acetaminophen.

o

Behavioral : Stress reduction techniques,

relaxation exercises, and physical therapy

to relieve muscle tension.

o

Preventive : For chronic tension

headaches, low-dose antidepressants like

amitriptyline may help.

3.Cluster Headache :

o

Abortive : 100% oxygen therapy,

sumatriptan injections, or nasal sprays.

o

Preventive : Verapamil (calcium

channel

blocker), corticosteroids during the cluster

period.

Conclusion and Next Steps



Migraine or tension-type headache seem

most likely based on the patient’s age, gender,

and common headache patterns.



If her headaches are well-controlled with over-

the-counter pain relievers and have no red

flags, it’s likely benign.



If her headaches are frequent , disabling , or

associated with aura/nausea, migraine

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prophylaxis and a headache diary are good

options to track and manage triggers.



If any red flags are present, further evaluation

with imaging or lab tests would be necessary.

1. Detailed History and Diagnostic Questions



Onset : How long has the patient been

experiencing these headaches? Was the onset

sudden or gradual?



Frequency and Duration : How often do the

headaches occur? How long do they typically

last?



Location : Is the pain predominantly on one

side (suggesting migraine ) or more

generalized/bilateral (suggesting tension-type

headache )?



Quality of Pain : Is the pain

throbbing/pulsating (consistent with migraine )

or a dull, pressing/tight sensation (more

consistent with tension headache )?



Associated Symptoms :

o

Does the patient experience nausea,

vomiting , or sensitivity to light/sound

(suggestive of migraine )?

o

Any visual disturbances (aura), such as

flashes of light , zigzag lines , or blind

spots , before the headache?

Comprehensive

o

Any tearing of the eyes , nasal

congestion , or autonomic symptoms

(suggesting cluster headache )?



Triggers : Are there any specific triggers

like

stress , lack of sleep , hormonal changes

(menstrual cycle), or certain foods that

precede the headaches?



Aggravating/Relieving Factors : Does

physical activity worsen the headache? Does

resting in a dark room help?

2. Physical Examination



General Exam : Assess vital signs, including

blood pressure, to rule out hypertensive

causes.



Neurological Exam : Perform a detailed

neurological examination to check for any

focal neurological deficits such as weakness,

visual disturbances, or coordination issues.

This would help exclude more serious causes

such as stroke or brain tumor.



Palpation : Check for tenderness or tightness

in the neck and shoulder muscles , which may

indicate tension-type headaches. This could

also reveal any musculoskeletal involvement.

Comprehensive



Sinus Examination : Evaluate for sinus

tenderness or congestion to rule out sinusitis as

a secondary cause.

3. Diagnostic Workup (if Needed)



If no red flags are present and the history and

physical exam are consistent with a primary

headache disorder, imaging may not be

necessary. However, if there are concerning

signs (e.g., new-onset headache, focal

neurological findings, or changes in headache

pattern), consider the following:

o

CT or MRI of the brain to rule out

secondary causes like tumors or vascular

abnormalities.

o

Lumbar puncture if there are signs of

meningitis (e.g., fever, neck stiffness) or

intracranial pressure (e.g., papilledema).

o

Blood tests for inflammatory markers like

ESR and CRP if giant cell arteritis is

suspected (though rare in young patients).

4.Diagnosis (Primary Headache

Disorders Likely)

Based on the findings, the most probable

diagnoses are either migraine or tension-type

headache :

Comprehensive



Migraine : If the patient experiences

throbbing , unilateral pain with nausea ,

vomiting , and/or photophobia/phonophobia ,

and the headaches last from 4 to 72 hours.



Tension-Type Headache : If the pain is

bilateral , feels like a tight band , and is

associated with muscle tension , stress , and

poor posture , with little to no nausea.

5.Management

Strategy For Migraine:

1.Abortive Treatment :

o

NSAIDs (e.g.,

ibuprofen,

naproxen) or

acetaminophen

at the onset of a

migraine.

o

Triptans (e.g., sumatriptan, rizatriptan) if

the headache is moderate to severe.

o

Anti-nausea medications (e.g.,

metoclopramide, prochlorperazine) if

nausea is a major symptom.

o

Ergotamines (less commonly used

but

can be effective in certain patients).

2.Preventive Treatment (for frequent or severe

migraines):

o

Beta-blockers (e.g., propranolol).

o