A 14-year-old girl is brought to the office due to recurrent headaches. The headaches began 2 weeks ago while she was studying for end-of-semester exams. Since then, the patient has had headaches almost daily but has been able to continue school and other daily activities. The headaches are of moderate intensity, bifrontal, non-throbbing, exacerbated by loud noise, and relieved by sleep. She has had no nausea or vomiting. Her mother has a history of migraine. Vital signs are within normal limits. BMI is 28 kg/m². Nasal and oropharyngeal mucosae and tympanic membranes are normal. Neurological examination shows normal bilateral pupillary response and normal motor strength, sensation, and deep tendon reflexes. There is no neck rigidity. Which of the following is the most likely cause of this patient's headaches?

Question

Quizplus · Accepted Answer

Explanation: 11ec2b69_c193_9dc0_8f63_6f69ddce5c50_MD0005_00 This patient developed headaches during a period of stress and now has periodic, bifrontal, non-throbbing headaches, suggesting tension-type headache (TTH). TTHs are the most common form of headache in children, occurring 2-3 times more frequently than migraines. Unlike migraines, TTHs tend to be non-throbbing, bilateral, and band-like. Daily activities are rarely affected, and abdominal pain, nausea, and vomiting are unusual. Phonophobia or photophobia may occur, but the presence of both indicates an alternate diagnosis. Patients with TTH typically have a normal neurologic examination but may have tenderness or trigger points in the musculature at the base of the occiput. Diagnosis is made based on characteristic clinical findings. Treatments with pharmacologic (eg, acetaminophen), behavioral, or stress-reductive therapies are often helpful. (Choice A) Intracranial tumors may present with symptoms similar to those of TTH. However, intracranial tumors often cause headaches in the occipital region that progressively worsen over time. In addition, neurologic function is often affected. This patient with intermittent, bifrontal headaches and a normal neurologic examination is more likely to have TTH. (Choice B) Frontal sinusitis can cause headaches, but patients usually have prominent nasal symptoms (eg, purulent discharge, congestion). This patient's nasal examination is normal. (Choice C) Idiopathic intracranial hypertension primarily occurs in obese women of childbearing age and is usually associated with severe, throbbing, unilateral headache, papilledema, and vision changes (eg, diplopia, blurriness). This child with a bifrontal, non-throbbing headache that does not interfere with daily function and a normal neurologic examination is unlikely to have idiopathic intracranial hypertension. (Choice D) Migraine headaches are also common in children but are usually throbbing and disabling and are more likely to be associated with nausea, vomiting, and both phonophobia and photophobia. Educational objective: Tension headaches are typically non-throbbing, bilateral, and band-like. Daily activities are rarely affected and nausea and vomiting are unusual. Patients may occasionally have associated phonophobia or photophobia but do not have both together.

A 14-Year-Old Girl Is Brought to the Office Due to Recurrent