A 61-year-old woman comes to the office accompanied by her daughter due to headaches. The headaches occur 2 or 3 times a week and feel like "a band around my head that someone is constantly tightening." The patient also reports excessive tiredness, restless sleep, and decreased appetite, attributing these symptoms to aging. She has no visual disturbances, dizziness, vomiting, weakness, or other neurologic symptoms. The patient experienced similar headaches a few years ago; after they restarted 2 months ago, she was persuaded by her daughter to get evaluated. The daughter mentions that her mother moved in with her a few months ago due to recent unemployment and financial concerns. Since moving, the patient has not been going out with friends and says, "I get anxious driving from my daughter's house because I don't know the roads." She was diagnosed with type 2 diabetes mellitus 2 years ago; hemoglobin A1c was 5.8% 2 months ago. Medications include metformin and ibuprofen as needed. Medical history is otherwise noncontributory. Vital signs are within normal limits, and physical examination is unremarkable. Which of the following is the most appropriate next step in management of this patient?

Question

A 61-year-old woman comes to the office accompanied by her daughter due to headaches.  The headaches occur 2 or 3 times a week and feel like "a band around my head that someone is constantly tightening."  The patient also reports excessive tiredness, restless sleep, and decreased appetite, attributing these symptoms to aging.  She has no visual disturbances, dizziness, vomiting, weakness, or other neurologic symptoms.  The patient experienced similar headaches a few years ago; after they restarted 2 months ago, she was persuaded by her daughter to get evaluated.  The daughter mentions that her mother moved in with her a few months ago due to recent unemployment and financial concerns.  Since moving, the patient has not been going out with friends and says, "I get anxious driving from my daughter's house because I don't know the roads."  She was diagnosed with type 2 diabetes mellitus 2 years ago; hemoglobin A1c was 5.8% 2 months ago.  Medications include metformin and ibuprofen as needed.  Medical history is otherwise noncontributory.  Vital signs are within normal limits, and physical examination is unremarkable.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

This patient's classic description of tension-type headaches, normal examination, and other symptoms suggestive of depression (eg, poor sleep, loss of appetite, fatigue, anxiety), may indicate an underlying psychiatric disorder. Patients with depression or anxiety often come to the office with headaches or other physical symptoms (eg, fatigue, insomnia, nonspecific aches and pains) due to a lack of psychologic awareness or a perceived stigma around mental health issues. In the absence of new physical findings in a medically stable patient, the most appropriate next step is to screen the patient for depression by specifically inquiring about depressive symptoms (eg, depressed mood, anhedonia). For patients who may be unaware of or reluctant to admit to feeling depressed, asking if they are able to enjoy their usual activities is helpful. (Choice A) Obtaining further collateral information from the daughter may be useful but should not take precedence over obtaining a thorough history from the patient. (Choice C) Neuroimaging would not be helpful because this patient describes typical tension-type headaches similar to those she had a few years ago. In addition, her neurologic examination is normal. (Choice D) This patient has stable glycemic control as demonstrated by the normal hemoglobin A1c level taken 2 months ago; a repeat hemoglobin A1c level is not indicated at this time. (Choice E) Although reassurance regarding the benign nature of the headaches and regular follow-up is indicated, assessment for depression is a priority given the other symptoms suggestive of this condition. (Choice F) Although relaxation techniques and biofeedback can be considered in the management of tension-type headaches, it would be premature to recommend this intervention prior to evaluating for depression. (Choice G) Although giant cell arteritis (evaluated by temporal artery biopsy) can cause headache and fatigue, it is typically characterized by new headaches, abrupt onset of visual disturbances, jaw claudication, and constitutional symptoms such as fever. This patient's headaches are suggestive of recurrent tension-type headaches. Educational objective: Patients with underlying mood disorders frequently come to the office with physical rather than psychologic symptoms. Evaluation should include screening for depression by inquiring about mood and ability to enjoy usual activities. References: Patients presenting with somatic complaints in general practice: depression, anxiety and somatoform disorders are frequent and associated with psychosocial stressors. (http://www.ncbi.nlm.nih.gov/pubmed/20843358) Overlap between headache, depression, and anxiety in general neurological clinics: a cross-sectional study. (http://www.ncbi.nlm.nih.gov/pubmed/27270532)

A 61-Year-Old Woman Comes to the Office Accompanied by Her