A 13-year-old girl is brought to the emergency department for a headache that has been worsening for the past 24 hours. The patient developed a headache yesterday morning after she returned home from a sleepover at a friend's house. The headache is located over the right frontal area and is pulsatile in quality. The patient has had similar headaches starting 2 years ago, initially occurring every other month but, over the last year, occurring monthly. She had difficulty completing her online homework assignments for school today due to worsening pain. The patient has also had intermittent nausea and vomited twice today. Acetaminophen has minimally improved the pain, and physical activity exacerbates the symptoms. Menarche occurred at age 12, and menstrual periods are regular. Temperature is 37 C (98.6 F), blood pressure is 110/72 mm Hg, pulse is 90/min, and respirations are 18/min. The patient is alert and oriented. The pupils are equal and reactive to light. The remainder of the neurologic examination is normal. Which of the following is the best next step in evaluation of this patient?

Question

A 13-year-old girl is brought to the emergency department for a headache that has been worsening for the past 24 hours.  The patient developed a headache yesterday morning after she returned home from a sleepover at a friend's house.  The headache is located over the right frontal area and is pulsatile in quality.  The patient has had similar headaches starting 2 years ago, initially occurring every other month but, over the last year, occurring monthly.  She had difficulty completing her online homework assignments for school today due to worsening pain.  The patient has also had intermittent nausea and vomited twice today.  Acetaminophen has minimally improved the pain, and physical activity exacerbates the symptoms.  Menarche occurred at age 12, and menstrual periods are regular.  Temperature is 37 C (98.6 F), blood pressure is 110/72 mm Hg, pulse is 90/min, and respirations are 18/min.  The patient is alert and oriented.  The pupils are equal and reactive to light.  The remainder of the neurologic examination is normal.  Which of the following is the best next step in evaluation of this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d5de_382d_bc81_6de8df8c912f_MD0003_00 This patient's unilateral, pulsatile headache with associated nausea and vomiting is consistent with a migraine headache. Migraine is a primary headache disorder most common in adolescent girls and women. Common triggers include sleep deprivation, stress, menses, and fasting. This patient's recent sleepover may have provoked the current episode due to change in sleep hygiene or sleep deprivation. In addition, the increase in migraine frequency since menarche may be related to monthly menses. Migraines are classically episodic, unilateral headaches with a throbbing or pulsatile quality. They may persist for up to 3 days, and nausea and vomiting are common. Symptoms are typically exacerbated by loud noises (phonophobia), bright lights (photophobia), and physical activity, although rest in a dark, quiet room is alleviating. Neurologic examination is normal. Diagnosis of migraines is clinical. Laboratory evaluation is not warranted (Choice E). Neuroimaging (eg, CT scan of the head, brain MRI) is indicated for features suggesting an alternate, life-threatening diagnosis (Choice A), including the following: Abnormal neurologic examination (eg, weakness, ataxia) Signs of increased intracranial pressure (eg, headache waking patient from sleep, papilledema) Rapidly increasing headache frequency Initial management of a migraine is simple analgesia (eg, acetaminophen, nonsteroidal anti-inflammatory drugs). Refractory headaches are treated with a triptan (ie, serotonin receptor agonist). (Choice B) This patient has had no abnormal movements suggestive of seizure activity, making electroencephalography unnecessary. (Choice C) Lumbar puncture is warranted for concern for meningitis. However, this patient is afebrile and has a normal neurologic examination. In addition, although nausea and vomiting can suggest elevated opening pressure (characteristic of idiopathic intracranial hypertension), papilledema would be expected. (Choice F) Signs of toxic ingestion include altered mental status, pupillary abnormalities, respiratory depression, and seizures. Episodic headaches with classic migraine characteristics make urine toxicology unnecessary. Educational objective: Classic migraine presents with a unilateral and pulsatile headache, phonophobia, photophobia, nausea, and/or vomiting. Common triggers include sleep deprivation and menses. Imaging and laboratory evaluation are not warranted for patients with classic symptoms and a normal neurologic examination. References: Headache: migraine. (http://www.ncbi.nlm.nih.gov/pubmed/30346679)

A 13-Year-Old Girl Is Brought to the Emergency Department for a Headache