A 57-Year-Old Woman Comes to the Office with Intermittent Headaches

A 57-year-old woman comes to the office with intermittent headaches, shoulder and neck pain, fatigue, and insomnia.  The headaches sometimes interfere with the patient's ability to concentrate at work.  The symptoms are not new but have worsened over the past 8 months due to the stress of starting a new job and placing her elderly mother in an assisted living facility.  The patient lies awake at night worrying about her mother, her own health problems, and the finances of her 2 adult children, who are having difficulty supporting themselves.  During the day, she is tired due to poor sleep and worries about her job performance.  The patient has a history of hypertension, irritable bowel syndrome, and tension headaches.  She drinks 1 or 2 glasses of wine before bedtime a few times per week to help her relax and fall asleep.  Temperature is 36.7 C (98 F) , blood pressure is 130/80 mm Hg, pulse is 88/min, and respirations are 16/min.  Examination shows sweaty palms and mild, diffuse abdominal tenderness; no other abnormalities are noted.  Complete blood count, chemistry panel, TSH, urinalysis, and ECG are normal.  Which of the following is the most appropriate next step in management of this patient?

A) Begin clonazepam and supportive psychotherapy
B) Begin escitalopram and recommend cognitive-behavioral therapy
C) Obtain noncontrast CT scan of the head and neck
D) Obtain urinary fractionated catecholamines and metanephrines
E) Obtain urinary porphobilinogens
F) Reassure the patient that serious medical illness has been ruled out
G) Schedule monthly visits to monitor symptoms