A 28-year-old man comes to the office for a health maintenance visit. He has no history of serious illness but reports periodic headaches over the last several years that often respond to acetaminophen. Occasionally the headaches are severe enough to necessitate taking a sick day from work. He cannot recall specific triggers but notes that the headaches are usually unilateral. The patient does not use tobacco or illicit drugs. He drinks alcohol socially and 2-3 cups of coffee daily. He is a software engineer and often works at a computer 10-12 hours a day. His sister has a history of migraines. Vital signs are within normal limits. Physical examination, including neurological examination, is normal. Item 1 of 4
Which of the following is the best next step in management of this patient's headaches?

Question

Quizplus · Accepted Answer

Explanation: This patient has had several years of episodic headaches that occasionally interfere with work. He is otherwise healthy and has a normal neurological examination. These features suggest a benign form of headache such as tension-type, migraine, or cluster. Additional information is now required to differentiate these etiologies; the patient should keep a headache diary to record headache triggers, headache length, associated symptoms, and palliative techniques and then return for follow-up. Although this patient has features consistent with a benign cause of headache, headaches can also indicate a serious underlying condition such as brain mass, infection, or hemorrhage. Danger signs indicating a potentially life-threatening cause of headache include the following: Systemic symptoms (eg, fever) or illness (eg, cancer) Neurological signs/symptoms Onset is new Other associated conditions (eg, head trauma) Previous headaches with change in frequency, severity, or presentation Patients with any of these findings usually require urgent investigation, often including brain imaging (eg, MRI) (Choice B). (Choice A) Patients who take analgesics (eg, acetaminophen) for headaches >10 days/month for >3 months can develop a secondary headache disorder due to medication overuse. Prior to recommending cessation of acetaminophen, this patient should keep a headache diary to clarify the number of headaches per month and associated acetaminophen use. (Choices C and D) Acute migraine headaches can be treated with nonsteroidal anti-inflammatory medication and sumatriptan, and tension-type headaches can be treated with lifestyle modification and reassurance. However, additional information about the headache type, location, timing, and associated symptoms is required prior to making either of these diagnoses. Educational objective: The cause of headache can often be differentiated based on history and physical examination. Headache diaries can help gather data on headache frequency, duration, intensity, associated symptoms, and medications used for treatment. References: Headache diaries and calendars. (http://www.ncbi.nlm.nih.gov/pubmed/20816416)

A 28-Year-Old Man Comes to the Office for a Health