A 48-year-old woman comes to the office due to episodic headaches. The patient has had occasional headaches, but during the past month, they have become more frequent without any significant change in quality. She describes the headaches as constant pressure in the temporal and occipital regions, frequently developing in the afternoon. The patient is able to carry out daily activities during the headaches, but they are often bothersome, so she takes acetaminophen. She has had no nausea or visual disturbances. The patient's medical history includes hypertension, hyperlipidemia, and fibromyalgia. She does not use tobacco, alcohol, or illicit drugs. Her sister recently died of a glioblastoma. Temperature is 37.0 C (98.6 F), blood pressure is 140/90 mm Hg, and pulse is 82/min. Bilateral pupils are equal and reactive to light. Motor strength, sensation, and deep tendon reflexes are normal. Which of the following is the most likely cause of this patient's headaches?

Question

A 48-year-old woman comes to the office due to episodic headaches.  The patient has had occasional headaches, but during the past month, they have become more frequent without any significant change in quality.  She describes the headaches as constant pressure in the temporal and occipital regions, frequently developing in the afternoon.  The patient is able to carry out daily activities during the headaches, but they are often bothersome, so she takes acetaminophen.  She has had no nausea or visual disturbances.  The patient's medical history includes hypertension, hyperlipidemia, and fibromyalgia.  She does not use tobacco, alcohol, or illicit drugs.  Her sister recently died of a glioblastoma.  Temperature is 37.0 C (98.6 F), blood pressure is 140/90 mm Hg, and pulse is 82/min.  Bilateral pupils are equal and reactive to light.  Motor strength, sensation, and deep tendon reflexes are normal.  Which of the following is the most likely cause of this patient's headaches?

Quizplus · Accepted Answer

11ec25c8_d298_aae2_bc81_cd7e40b722c4_MD0003_00 This patient with headaches that manifest as constant pressure in the temporal and occipital regions without nausea or visual symptoms (eg, photophobia) and that are unchanged (although more frequent) from prior likely has tension-type headaches (TTHs). These are more common in women, are usually bilateral, last 30 minutes to a week, and can be associated with muscle tenderness of the head and neck. They can become more frequent during periods of stress (eg, recent death of a relative, as with this patient). Patients with intermittent TTHs (<1 day/month) can use analgesics (eg, ibuprofen, aspirin), which can be combined with caffeine without concern for developing medication overuse headache. Those patients with more frequent TTHs that last for long periods or are disabling should be considered for prophylactic medication (eg, amitriptyline, nortriptyline) as well as cognitive behavior therapy to learn stress-reduction techniques. < (Choice A) Brain tumors typically present with progressive morning headache associated with frequent nausea and vomiting with possible seizure or neurologic deficits due to mass effect. (Choice B) Cluster headaches generally present with unilateral recurrent periorbital pain that resolves and recurs with associated ipsilateral miosis and ptosis. The pain can be excruciating, and patients are often agitated. (Choice C) Giant cell arteritis should be considered in patients age >50 with new-onset headaches usually localized to the temples and frequently associated with fever, weight loss, vision changes, and jaw claudication (ie, fatigue and pain when chewing). (Choice D) Patients with hypertensive encephalopathy can have symptoms related to cerebral edema (eg, headache, nausea, vomiting) due to a rapid and significant rise in blood pressure (eg, >180/120 mm Hg). > (Choice E) Patients with TTHs can have concomitant major depression, but this patient does not appear to have depressed mood, anhedonia, sleep disturbances, or other prominent manifestations of depression. In addition, depression alone is unlikely to cause the symptoms the patient describes. (Choice F) Migraine without aura is usually associated with nausea, vomiting, and photophobia. The headaches are typically described as pulsatile and throbbing in character and are often unilateral. Educational objective: Tension-type headaches can occur due to stress and are usually bilateral, dull, and nonthrobbing without associated symptoms (eg, nausea, vomiting). When infrequent, they can be treated with analgesics (eg, ibuprofen), but when more disabling, prophylactic medication (eg, amitriptyline) should be considered. References: Headache as a symptom of ominous disease. What are the warning signals? (http://www.ncbi.nlm.nih.gov/pubmed/9158606) Evidence for efficacy of acute treatment of episodic tension-type headache: methodological critique of randomised trials for oral treatments. (http://www.ncbi.nlm.nih.gov/pubmed/25139586)

A 48-Year-Old Woman Comes to the Office Due to Episodic