Case 26: Headache

Opening scenario

Adam Graham, a 29-year-old male; , comes to the urgent care clinic because of a headache.

Vital signs

• Temperature: 97.9°F (36.6°C)
• Blood pressure: 120/70 mm Hg
• Heart rate: 70/min
• Respirations: 18/min

Examinee tasks

• Take a focused history.
• Perform a relevant physical examination (do not perform corneal reflex, breast, pelvic/genitourinary, or rectal examinations).
• Explain the preliminary differential diagnoses and initial workup plan to the patient.
• Write the patient notes after leaving the room.

Patient instructions

• Mention that the light makes your headache worse. If the examinee does not offer to dim the light in the room after you mention this, start giving very short answers and do not give away any information that the examinee does not specifically ask for.
• You are unaware of the meanings of medical terms (e.g., CT) and ask for clarification if the examinee uses them.
• Use the checklists below for history, physical examination, and communication and interpersonal skills.

Challenge: Interrupt the examinee while he or she is taking your patient history and say “I have a job interview this afternoon. Can you not just give me some medication so that this headache goes away and I can go to the interview?”

Hovering over the speech bubbles in the lists below will reveal extra information about the adjacent term. However, clicking on links will cause you to navigate away from the current case, at which point your progress (i.e., your check marks) will be lost. If you do want more information on a subject, either open the link in a new tab or wait until you and your partner have finished the case and reviewed the check marks. Following the link to the patient note form will not interrupt your progress.

History of present illness

• Chief complaint
• I have a headache.
• Location
• On the right side of my head; , particularly my forehead and the area around my eye.
• Intensity (on a scale from 0–10)
• It is a 7–8.
• Quality
• It is a throbbing pain.
• Onset
• It started this morning, so maybe 2 hours ago.
• Precipitating events
• No, I do not remember anything in particular.
• Progression/constant/intermittent
• It is getting worse.
• Previous episodes
• I have had occasional headaches in the past but never this bad and not often, maybe once every other month.
• Radiation
• Well, it hurts the most in the front, but really the entire right side of my head is throbbing. I do not have pain anywhere else though, if that is what you mean.
• Alleviating factors
• If I lay down and do not move, my head feels a little bit better.
• Aggravating factors
• Moving; . And the bright light in this room also makes it worse.
• Associated symptoms
• I feel a little bit nauseous but I have not vomited.

Review of systems specific to headache

• Trauma
• No.
• Fever/chills
• No.
• Sleep problems
• I have been really stressed lately because I am trying to find a new job, so I often stay up late to write applications. I have trouble falling asleep with so much on my mind, anyway, so I might as well do something productive.
• Appetite
• My appetite has been good. Last night I actually got really hungry and ate two cans of ravioli.
• Recent infections
• No.
• Dizziness
• No.
• Visual disturbances
• No, light just makes my headache worse, but I can see fine.
• Difficulty speaking
• No.
• Weakness
• No.
• Tingling/numbness
• No.
• Mood
• I think my mood is generally good. I have just been really stressed out.
• Eyes tearing
• No.
• Nasal congestion/runny nose
• No.
• Restlessness
• No.
• Sweating
• Yes, I feel like my face is really sweaty.

Past medical history, family history, and social history

• Past medical history
• No.
• Allergies
• Penicillin.
  • Type of reaction
  • I got a really bad rash all over my body.
• Medications
• I tried to take some ibuprofen for the headache about an hour ago but it did not help. Other than that I do not take any medications.
• Hospitalizations
• None.
• Past surgical history
• None.
• Family history
• My mom had a stroke last year just before she turned 65. The rest of my family is healthy.
• Work
• I used to work as a project manager for a construction company, but they went out of business six months ago. I have been looking for a new job since then and have a job interview today.
• Home
• I live with my wife and my daughter.
• Alcohol
• I do not usually drink, but last night I drank some red wine with my wife to celebrate the fact that I finally got invited to an interview for a great job.
• Recreational drugs
• Never.
• Tobacco
• I have smoked about 2 packs a day since I was 15.
• Exercise
• I do not get to exercise much; I spend most of my time at home at my desk.
• Diet
• I think I typically have a balanced diet. Lately the money has been a little tight, so we have had to cook more ourselves, which is probably healthier than eating out all the time anyway.

• Washed hands
• Used respectful draping
• Head, eyes, ears, nose, and throat examination
  • Inspection of the head
  • Palpation of the head
  • Inspection of the conjunctivae
  • Visual acuity evaluation (Snellen chart)
  • Direct fundoscopy
• Neck examination
  • Inspection of the neck
  • Palpation of the neck
• Neurologic examination
  • Examination of orientation to person, place, and time
  • Focused examination of the cranial nerves
  • Meningism
  • Focused examination of passive and active motion
  • Focused examination of sensation
  • Focused examination of deep tendon reflexes
  • Focused examination of gait
  • Rapid alternating movement test
  • Finger-to-nose test
  • Babinski sign
  • Romberg test

Patient interaction

• Examinee knocked on the door.
• Examinee introduced him- or herself and identified his/her role.
• Examinee correctly used the patient's name.
• Examinee asked open-ended questions.
• Examinee listened attentively (did not interrupt the patient).
• Examinee showed interest in the patient as a person (i.e., appeared caring and showed respect).
• Examinee demonstrated the ability to support the patient's emotions (i.e., offered words of support, asked for clarification).
• Examinee discussed initial diagnostic impressions with the patient.
• Examinee explained the management plan.
• Examinee used non-medical terms and provided reasons for planned steps in management.
• Examinee evaluated the patient's agreement with the next diagnostic steps.
• Examinee asked about concerns or questions.

Counseling and challenge

• Examinee offered counseling on smoking cessation.
• Examinee gave the patient the option to lie down and offered to dim the light in the room.
• Examinee reacted appropriately to challenge.

Suggested response to challenge: ”Mr. Graham, I understand that the job interview is important to you. I can assure you that we will do our best to get you out of here as soon as possible. But before I give you any medication I would like to ask you a few more questions and perform a physical examination. It is important that I get a better idea of what is causing your headache so that I can treat you appropriately. Is that okay?”

Patient note

Differential diagnoses

1. Migraine attack: A prodrome (unusual appetite prior to the headache) followed by acute onset of a severe, throbbing, unilateral headache with nausea, and photophobia is typical of a migraine attack. This patient consumed red wine and has a history of lack of sleep, increased emotional stress due to unemployment, and smoking, which are all potential triggers of a migraine attack. Migraine does not have any specific findings on physical examination. In fact, abnormal physical examination would warrant further diagnostic tests to rule out dangerous causes of headache. Migraine can be diagnosed if there is a history of several migraine attacks (with aura: ≥ 2 attacks, without aura: ≥ 5 attacks).
2. Tension headache: Tension headache is the most common type of headache and may be triggered by fatigue, lack of sleep, anxiety, and/or stress. Especially since this patient does not have a prior history of migraines or cluster headaches, tension headache is an important differential. However, tension headache manifests holocranially or bifrontally and does not present with autonomic symptoms (e.g., nausea, sweating), nor is it aggravated by movement or light.
3. Cluster headache: This condition most often affects adult men with a peak incidence of 20–40 years and presents with recurrent, 15-minute to 3-hour attacks of agonizing, strictly unilateral headaches in the periorbital and forehead region and facial sweating, as seen in this patient. Smoking is a risk factor, and consumption of alcohol is a possible trigger. However, this type of headache also typically occurs during the night and presents with restlessness, agitation, and pronounced ipsilateral symptoms of increased cranial autonomic activity (e.g., lacrimation, conjunctival injection, rhinorrhea, partial Horner syndrome), which make this diagnosis the least likely in this patient.

The typical migraine headache is “POUND”: pulsatile, one-day duration, unilateral, nausea, disabling intensity.

Diagnostic studies

Migraine, tension headache, and cluster headache are clinical diagnoses that are based on patient history and physical examination and do not warrant diagnostic tests! Diagnostic tests should only be undertaken if any of the following red flags are present: severe unrelenting headache, fever, focal neurological deficits, seizures, impaired consciousness, signs of increased intracranial pressure (e.g., loss of consciousness, papilledema), signs of meningism, psychiatric symptoms, or eye pain.

Other differential diagnoses to consider

• Intracranial mass
• Meningitis
• Subarachnoid hemorrhage
• See also differential diagnoses of headache.