Headache follow-up

Age: ‍ years old

Gender: ‍malefemale



HISTORY:

Returns for a ‍headache follow-up

Last visit was ‍ ‍months ago

Progress since last visit: ‍unchangedimproveddeterioratedvariableresolved



Updates on symptoms:

‍headache, ‍diffuse, ‍persistentintermittent, ‍pressurethrobbing, ‍mild

‍nausea

‍vomiting, ‍ episodes ‍per day, ‍, ‍hematemesis

‍photophobia

‍phonophobia

‍aura

‍visual disturbances

‍dizziness

‍loss of consciousness



Medications:

‍acetaminophen, ‍NSAIDs, ‍triptans, ‍muscle relaxants, ‍opioids, ‍beta blockers, ‍antidepressants, ‍antiseizure medications, ‍others

Change at last visit: ‍ ‍introducedincreased, ‍effectiveineffective, ‍adverse effects

Use of rescue medication: ‍neverrarelyoccasionallyfrequentlydaily

Adherence: ‍goodaveragepoor



Lifestyle changes: ‍nonestress management, ‍effectiveineffective

Other interventions tried: ‍ ‍none, ‍physical therapy, ‍acupuncture, ‍massage, ‍biofeedback, ‍cognitive behavioral therapy, ‍effectiveineffective



Labs: ‍unremarkable

Head CT scan: ‍ ‍unremarkable

Head MRI: ‍ ‍unremarkable





EXAM:

General appearance: ‍well-appearing, ‍apparent distress

Vital signs: ‍normal, BP ‍, HR ‍, RR ‍, SpO2 ‍ %, Temp ‍°

Head: ‍normocephalicatraumatic, scalp ‍normalrashlesion

Eyes: conjunctiva/sclera ‍normal, lids/lashes ‍normal, cornea ‍intact, ‍PERRL, extraocular movements ‍intact, OD 20/‍, OS 20/‍

Ears: tympanic membranes ‍normal ‍, auditory canal ‍ on ‍rightleft, hearing ‍intact

Neck: ‍normal, ‍lymphadenopathy, ‍, c-spine ‍

Heart: ‍RRR, ‍MRG, ‍normal S1 and S2

Lungs: ‍clear bilaterally, ‍abnormal sounds, ‍retractions

Cervical spine: ‍tenderness on ‍, range of motion ‍fulllimited

Neurologic: cranial nerves ‍intact, strength ‍intact 5/5, sensation ‍intact, reflexes ‍intact 2+, cerebellar function ‍intact, gait ‍steady





ASSESSMENT:

‍Headache ‍likelysuspectedpossible, ‍well controlled

DDx: tension-type headache, migraine, cluster headache, chronic daily headache, medication overuse headache, sinusitis, neck pathology, giant cell arteritis, subarachnoid hemorrhage, meningitis, encephalitis, brain tumor, intracranial hemorrhage, pseudotumor cerebri, glaucoma, carbon monoxide poisoning, hypertension, caffeine withdrawal, dehydration, sleep disorders, sleep apnea, post-traumatic headache, cervicogenic headache, dental abscess





PLAN:

Investigations:

- CT scan of the brain

- MRI of the brain

- Blood work: ‍CBC, ‍TSH, ‍CRP, ‍ESR

Treatments:

- ‍Acetaminophen

- ‍NSAIDs

- ‍Triptans

- ‍Prophylaxis medications

- Regular exercise

- Stress management techniques

- Sleep hygiene

- Avoid triggers (e.g. caffeine, alcohol, stress)

- Avoid overuse of analgesics

Further care:

- Referral to neurologist

- Follow-up in ‍ ‍weeksmonths

- Return if headaches worsen, if new symptoms develop such as vision changes or weakness, or if symptoms do not improve with treatment