Migraine Headaches Patient

Nancy Smith

9/10/66 (46 years old)

Gender

Female

Race

African-American

Religion

Marital Status

Married

Occupation

Caregiver

Chief Complaint

Extremely painful headache that won't go away.

Differential Diagnosis:

Possible Diagnosis

Migraine Headache

Potential Diagnosis

Deep pounding headache more pronounced behind eyes;

- Headache has lasted more than 72 hours

- OTC Pain medications ineffective (Tylenol)

No accompanying nausea or vomiting

Physical Exam: Elevated blood pressure

Diagnostic Testing: Frequency of symptoms log; More than 72 hours of pain; Two or more of unilateral, pulsating, moderate or severe pain; not reporting nausea or sensitivity to light; lack of response to pain medication

TMJ (Tempormandibular Joint Disorder)

Unlikely Diagnosis

History: Emanating pain but no jaw spasm or difficulty chewing or biting

Physical Exam: No clicking or popping of TMJ when opening or closing mouth

-No inflammation of muscle around jaw

Diagnostic Testing: No jaw pain or face pain, no earache so unlikely diagnosis

Temporal Arteritis

Potential Diagnosis

History: Emanating pain, throbbing headache, general ill feeling

Physical Exam: No fever or loss of appetite; No tenderness over temporal artery

Diagnostic Testing: Pulse slightly elevated, but patient under 50. No vision blurring or double vision

Cluster Headache

Unlikely Diagnosis

History: Emanating pain quite severe

Physical Exam: Pain has lasted more than typical cluster; no nasal congesting or swelling of eyelids

Diagnostic Testing: Pain is not centered around the eye, but is in head area; lacks cluster periods

Concussion Headache

Unlikely Diagnosis due to lack of reported injury

History: Emanating pain

Physical Exam: Patient reports no injury; no contusion or obvious injury

Diagnostic Testing: No memory issues, tinnitus, dizziness, no report of fatigue

History of Present Illness:

Patient indicates headache began 48-72 hours previous and continues despite using cold compresses, Tylenol, or resting in dark areas. She indicates pain is "6" on scale of 1-10. Patient denies any accompanying issues such as nausea and vomiting, and has not reported any symptoms of auras. Patient reports no unusual issues at work or home, or stress related triggers. The two key aspects of patient's issue are the lack of relief and the continual pounding pain.

Past Medical History:

In general, patient is in good health. She is slightly overweight, but not obese. Her alcohol consumption is minimal, and she does not smoke and denies drug use. Her psychological profile does not indicate problems (depression, etc.). Previous headaches would last for a few hours and occur irregularly, with Tylenol or cold compresses offering relief.

Patient has had bi-annual physicals, reports no cardiac, renal or diabetes issues; has had no recent dental work or surgery. Patient is active but has no aggressive or formal exercise program, and reports an adequate sex life (intercourse 3-5 times per month). Patient does not have any menstrual problems, and is not experiencing menopause.

Allergies: None reported, may occasionally experience nasal symptoms at certain times in the Spring.

Medications (prescription): None

Medications (OTC): Regularly takes Women's One a Day Vitamin, uses 250-500 mg Tylenol for occasional headaches, occasionally uses Ibuprofen (300-500 mg) for menstrual pain.

Last Exam: Family MD - normal routine checkup 6 months prior, no issues uncovered; Gynecologist -- 9 months ago, schedules annual exam; Dental, 4 months ago, routine cleaning 2X annually

Childhood -- Chicken pox at age 9; denies measles, scarlet fever or rheumatic fever

Adult -- No history of high BP or Cholesterol, recent blood tests normal, no stroke, seizures, asthma, cancer, TB, alcoholism, Liver, Kidney or depression

Surgical -- Minor "mole" removal 4 years prior, carpal tunnel surgery 8+ years ago

OB/GYN -- Normal PAP smear and mammogram, sexually active with one partner, no birth control

Psychiatric -- Denies issues

Vaccinations: Flu 2 months prior, Tetanus, 5 years prior

Family History:

Paternal Father -- Deceased. age 81, 2005 from stroke

Paternal Mother -- Alive, age 75, arthritis, reasonable health

Paternal Grandfather -- Deceased, age 79, natural causes

Paternal Grandmother -- Deceased, age 72, car accident

Maternal Father -- Deceased, age 79, from heart attack

Maternal Mother -- Alive, age 77, hip replacement, diabetes

Maternal Grandfather -- Deceased, age 68, lung cancer (smoker)

Maternal Grandmother -- Deceased, age 75, natural causes

Siblings -- 1 older sister, 1 younger brother, deny any serious medical conditions

Children -- 2 adopted children, now 22 and 24 years old, living away at college

Social History:

Alcohol -- 1-2 glasses of red wine/week with dinner, very occasional cocktail.

Tobacco -- Denies ever using.

Drugs -- Denies ever using.

Exercise -- Active, walks 30-45 minutes at least 3X week; Swims occasionally.

Diet -- Modified South Beach by choice; high fruit and vegetables; rarely eats red meat, drinks no sodas, does keep hydrated with water

Physical -- Height 5'8," Weight, 140, BMI: 21.4

Review of Systems:

General -- Indications of good health with few complaints; severe headache is not part of her typical lifestyle.

Head -- 1-2 tension headaches per year, recent symptoms unusual.

Rationale -- probed for potential injury, vascular issues,...

None reported.
Eyes -- Wears corrective lens; demises pain, redness, tearing, halos or blurriness; no history of glaucoma and gets annual eye exam.

Rationale -- new Rx or changes in vision can sometimes trigger headaches. Nothing unusual reported.

Ears -- Denies any issues with hearing, ears and/or infections or discharge.

Nose/Sinus- No sinus issues, itching, nosebleeds.

Rationale -- Sinus headaches can often mask as migraines, but typically do not last over 24 hours.

Throat/Mouth - No bleeding gums, sore tongue, mouth sores, etc.; has most teeth, 4-5 fillings, no dentures, regular dental exams and cleaning.

Neck -- No lumps, goiters, pain, swollen glands.

Rationale -- Probe for inflammation or any changes in perceived vascular issues. Lack of blood flow to brain often results in migraine.

Cardiovascular -- Good BP, no history of CAD, MI, HTN, no recent ECG or Echo

Respiratory -- Normal, denies issues, usually gets Winter Flu/Cold in January after holidays. Sleeps soundly, 7 hours per night on average; no reports of apnea.

Gastrointestinal -- Occasional heartburn (2-3 times annually), no reported food allergies, no changes in bowel health, no hemorrhoids.

Rationale -- reviews of dietary triggers sometimes find clues in certain foods; however, many are anecdotal and lack rigorous scientific proof. Probing patient, though, we find no triggers.

Hematological -- Denies bruising easy, no history of anemia or blood clots. Blood panel normal at last exam.

Rationale -- Polycythemia Vera can contribute to headache pain, particularly in women over 40.

Neurological -- Denies depression, memory changes, speech impairment, paralysis or weakness. No history of stroke or cerebral issues.

Rationale -- Minor strokes can cause headache pain, but usually not long lasting without other symptoms.

Rationale -- Migraines are thought to be neurovascular -- starting in the brain and spreading to blood vessels. High levels of serotonin may be involved.

Physical Exam:

General appearance -- Patient is neat, well-kept, friendly, answers questions quickly and with high level of vocabulary; color appropriate for ethnicity, nail beds healthy, and memory intact.

Rationale -- clues with memory or ability to form words or understand complex clues could indicate stroke or other neurological disorder.

Vitals -- BP 128/92; Pulse 110, Temp 99.1

Rationale -- BP a bit high, likely due to pain threshold; slight temperature elevation, patient reports normal for her body. Does not suggest infection or cardiac manifestation.

Head Inspection -- Centered and normal, no masses or excess skin, no venous distention; Scalp smooth, no lumps, lesions, depression, tenderness; temporal artery normal, lymph nodes normal.

Rationale -- Assessing for any particularly neurological changes that might contribute to headaches.

Neck Inspection -- normal, symmetric, no masses, trachea normal; thyroid normal.

Rationale -- Assessing for possible infection, none found.

Eyes and Visual Acuity -- EOM intact, fields normal, tracking normal, gaze normal, no drifting, light reflex normal, no edema, no paralysis, conjunctiva normal, sclera normal

Rationale -- Visual issues sometimes accompany migraines; lack of focus, blurring, etc. Patient denies these symptoms.

Ears -- No masses, lesions or tenderness; external canals clear, no perforations

Rationale -- Probe for ear canal infection or issues.

Nose -- symmetric, no lesions, sense of smell normal, no discharge, mucosa normal

Rationale -- Probe for signs of infection

Sinus -- Normal, no tenderness, no discharge

Rationale -- Sinus infection or sinus related pain.

Mouth -- Breath -- non-malodorous; teeth clean, gums pink, no lesions, teeth healthy, tongue smooth, no lesions; full tongue movement.

Cardiac -- Normal; symmetrical patterns, skin warm and normal, regular pulse, slightly elevated BP

Lungs -- Normal breath sounds, denies pain or difficulty breathing, no lesions, resonant to percussion, no pain; no sounds of occlusion or excess mucous.

Abdomen -- normal, normal bowel sounds, no masses or tenderness, liver-non-palpable, negative on rebound tenderness; to friction rubs; no hernia, no dilated veins, all consistent with good health.

Diagnostic Tests:

Based on frequency of issue, not advising expensive testing at this time. However, if the headaches persist, become more frequent, pain level or symptoms increase, it may be wise to counsel patient that two tests might rule out any serious physiological issues:

CT Scan -- Imaging procedure that would uncover tumors, infections or other issues.

MRI -- Can scan for tumors, strokes, aneurysms, blood vessels, neurological issues or brain abnormalities. Of special not might be a study of neck vessels to chart blood flow to brain and/or possible small obstructions.

To rule out any infections, we could run a sedimentation rate to assess inflammation.

Differential Diagnosis:

EXAMPLE:

Diagnosis

Pertinent Positives

Pertinent Negatives

Headache intensity

6+ in pain

Headache longevity

Over 72 hours

Nausea

None

Vomiting

None

Auras

None reported

Vision Issues

Slight sensitivity to light

No blurring

Outset

Quick but consistent

Relief

No OTC relief

Genetics

About 1/2 of patients report family members with migraines; patient indicates siblings have occasional onset

Diagnosis:

Patient is not presenting symptoms that are consistent with infection, concussion, sinusitis, cardiac or cerebral bleeding, or stroke. The lack of previous migraines may be due to the age of the patient, as women over 40 tend to…