A 24-year-old woman comes to the office due to headaches that she has had every few months for the past 6-7 years. She describes these as left-sided and throbbing; they are associated with mild nausea, last for 12-18 hours, and improve after she rests in a dark and quiet room or takes ibuprofen. For the past month, she has been waking up almost daily with bifrontal headaches often accompanied by nausea and vomiting. She also has occasional blurry vision. The patient attributes these headaches to increased stress at work after being promoted to a supervisor position. She has had no fevers, focal weakness, or numbness. She has no other medical history and does not use tobacco, alcohol, or recreational drugs. Her mother and sister have migraine headaches. Temperature is 37 C (98.6 F), blood pressure is 120/80 mm Hg, and pulse is 72/min. Bilateral pupils are equal and reactive to light. She has a normal examination of the cranial nerves, motor strength, sensation, and deep tendon reflexes. Which of the following is the most appropriate next step in management of this patient?

Question

A 24-year-old woman comes to the office due to headaches that she has had every few months for the past 6-7 years.  She describes these as left-sided and throbbing; they are associated with mild nausea, last for 12-18 hours, and improve after she rests in a dark and quiet room or takes ibuprofen.  For the past month, she has been waking up almost daily with bifrontal headaches often accompanied by nausea and vomiting.  She also has occasional blurry vision.  The patient attributes these headaches to increased stress at work after being promoted to a supervisor position.  She has had no fevers, focal weakness, or numbness.  She has no other medical history and does not use tobacco, alcohol, or recreational drugs.  Her mother and sister have migraine headaches.  Temperature is 37 C (98.6 F), blood pressure is 120/80 mm Hg, and pulse is 72/min.  Bilateral pupils are equal and reactive to light.  She has a normal examination of the cranial nerves, motor strength, sensation, and deep tendon reflexes.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: This patient has 2 different types of headache, one of which is likely a migraine (eg, infrequent, unilateral throbbing pain, mild nausea, improvement with rest) that has been unchanged for years, and a new type that is different in character (eg, headache on awakening) and associated with concerning symptoms (eg, nausea and vomiting, blurry vision). When a patient presents for evaluation of a headache, it is important to assess for warning signs that should lead to the consideration of early imaging, including: Neurologic findings: Seizure, changes in consciousness, specific deficits Differences compared to prior headaches: Change in frequency, intensity, characteristics Other: New at age >40, sudden onset, trauma, present on awakening This patient's new headache and her associated symptoms are worrisome for elevated intracranial pressure (eg, from mass effect) and should be evaluated early with an MRI of the brain to determine the cause. (Choice A) Cerebral CT angiogram is generally performed when there are concerns for a subarachnoid hemorrhage from a ruptured arterial aneurysm, which can present with sudden-onset severe headache ("worst headache of my life"), nausea, and decreased level of consciousness. (Choices B and C) Citalopram and lorazepam can be appropriate for patients with depression and anxiety related to stressors in their lives, whereas cognitive-behavioral therapy would be appropriate for patients having difficulty coping with stressors (eg, new supervisory role at work). However, this patient has worrisome findings that require further evaluation first. (Choice D) Analgesic overuse (eg, daily use) can cause rebound headaches, which generally improve with the gradual withdrawal of analgesics. However, this patient gives no indication that she is overusing analgesics, and rebound headaches are unlikely to cause daily bifrontal headaches with nausea, vomiting, and blurry vision. (Choice F) As-needed sumatriptan with prophylactic topiramate would be appropriate in a patient suffering from frequent migraines, but this patient's new headache is different from her prior ones and warrants further evaluation first. (Choice G) Inhaled oxygen and prophylactic verapamil would be appropriate for a patient with cluster headaches, which are characterized by unilateral, severe, recurrent orbital and temporal pain associated with ipsilateral ptosis, miosis, and rhinorrhea. Educational objective: Headaches that are new or differ in character from prior, that are present on awakening, and that are associated with frequent nausea and vomiting as well as blurry vision are concerning for a pathological cause. These patients should be evaluated early with an MRI of the brain. References: Headache as a symptom of ominous disease. What are the warning signals? (http://www.ncbi.nlm.nih.gov/pubmed/9158606) Diagnosis and treatment of headache in the ambulatory care setting: a review of classic presentations and new considerations in diagnosis and management. (http://www.ncbi.nlm.nih.gov/pubmed/24758958)

A 24-Year-Old Woman Comes to the Office Due to Headaches