Response to DQ question
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A 35-year-old woman comes to your office to discuss her “bad headaches,” which started after having her first child 2 years ago. The headaches sometimes awaken her from sleep and at times can be disabling and occasionally require her to take Tylenol and rest in a dark room. Sometimes she vomits during an attack. Over the past 6 months, her headaches have become more severe and frequent, prompting her visit today.
What additional questions would you ask to learn more about her headaches?
I would want to ask for specific frequency and duration. How would she rate them on a pain scale? Where is the pain? Is the pain throbbing, pressure, sharp, dull and achy? Do you experience sensitivity to light and sound? Any vision changes? Anything that seems to bring them on? Any numbness or tingling? Does the Tylenol make the headache go away? Does sleep help? Is the headache associated with any nasal congestion, facial pain or pressure? How long does it take for the pain to be it’s worst?
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How was your pregnancy? Any complications with pregnancy or delivery?
How do you classify headaches?
Headaches can be classified tension, migraine with or without aura, cluster, traction or inflammatory headache (Dunphy, Winland-Brown, Porter, Thomas, 2015). They can be acute or chronic. There are a number of other classifications, such as headache following injury, medication headache, headache from psychiatric illness etc.
How can you determine if this is an old headache or a new headache/s? Is this a chronic or episodic condition?
I would question the patient about her headache history. Maybe this is gradually worsening of an already chronic problem. I would want to know if she has had headaches in the past. If so, what were the symptoms of them? Same symptoms but just more intense now? Or different symptom profile altogether?
Can you make a definite diagnosis through an open-ended history followed by focused questions?
I would not want to make a definite diagnosis through history and questions alone. I could make a suspected diagnosis through this collection of information but a definite diagnosis would need to come after testing reveals it or a diagnosis has been established through ruling out or exclusion. The International Headache Society (2013) diagnostic criteria often includes ruling out of masses, vascular and structural abnormalities and no other diagnosis to better account for symptoms.
How can you use the patient history to distinguish between benign headaches and serious ones that require urgent attention?
Some key points that may be of concern would be onset of headache after age 50, sudden onset of headache, headache increasing in frequency and severity, new onset headache with risk factors for HIV infection, headache with fever, rash, or stiff neck, focal neurological symptoms, headache after head trauma (Clinch, 2001).
What diagnostic tests do you want to include to help you with your diagnosis?
I would consider a MRI or CT to check for tumors, structural causes, vascular causes. Bloodwork such as CMP, CBC, TSH, Vitamin D should be done. A quick vision test on a Snellen chart would let you know if the patient needs to see an eye doctor. Some patients with certain presenting factors should be have a temporal artery biopsy to rule out temporal arteritis.
Create a differential diagnosis flow sheet for this patient and include the diagnostics related to the differentials.
Brain tumor- CT or MRI and referral to neurosurgeon and oncology if positive.
Menstrual headache- Consider birth control to help with hormonal shift each month or 3 month birth control to lessen total number of periods every year.
Bloodwork irregularities- Correcting irregularities with medicine, fluids, dietary changes.
Hypertension- Check BP in office, have patient check during headache episode.
Stroke/TIA- CT or MRA
Meningitis- Lumbar puncture
Sinusitis- No diagnostics at first, may treat with antibiotic. If no resolution of symptoms, would consider CT for evaluation of chronic sinus disease.
References
Dunphy, L.M., Winland-Brown, J.E., Porter, B.O., Thomas, D.J. (2015). Primary care: The art and science of advanced practice nursing. (4th ed). F.A. Davis Company: Philadelphia.
Forbes, R. B. (2(014). Acute Headache. The Ulster Medical Journal, 83(1), 3–9.
Clinch, C.R. (2001). Evaluation of acute headaches in adults. American Family Physicians. Retrieved from https://www.aafp.org/afp/2001/0215/p685.html.
