Subjective:

Ms. X, a 37-year-old female, presents to the clinic with a complaint of severe headaches for the past two weeks. She reports that the pain is located at the front of her head, above her eyes, and is a constant dull ache that worsens throughout the day. She rates her pain as an 8 out of 10 and states that it is affecting her daily activities, including work and sleep. She has been taking over-the-counter pain medication, but it provides only temporary relief. She denies any history of trauma, recent illnesses, or allergies. She reports that she has a family history of migraines.

Objective:

During the physical examination, Ms. X’s vital signs were within normal limits. Her head and neck exam were unremarkable, with no signs of tenderness or palpable masses. A neurologic examination was conducted, which revealed no abnormalities in her cranial nerves, motor, or sensory function. The examination did not reveal any signs of nystagmus, tremors, or gait abnormalities.

Assessment:

Ms. X presents with a complaint of severe headaches that have been present for the past two weeks. The location and description of her pain are consistent with the criteria for tension-type headaches. However, the fact that the headaches are worsening throughout the day and are affecting her daily activities raises the possibility of a migraine headache. Furthermore, her family history of migraines increases the likelihood of this diagnosis.

Differential Diagnosis:

Tension-Type Headache: This is the most likely diagnosis given the location and quality of her pain. However, the worsening of her symptoms throughout the day and her family history of migraines suggest that this diagnosis may not be accurate.

Migraine Headache: The location and quality of her pain, along with the worsening of her symptoms throughout the day and her family history of migraines, raise the possibility of a migraine headache.

Cluster Headache: Although less likely, the unilateral location of her pain and its severity may suggest the possibility of a cluster headache.

Plan:

Ms. X will be advised to keep a headache diary, recording the frequency, intensity, duration, and associated symptoms of her headaches. She will also be advised to avoid triggers such as alcohol, caffeine, and certain foods that may exacerbate her symptoms. Non-pharmacological treatments such as relaxation techniques, stress reduction, and biofeedback will be recommended. Over-the-counter analgesics will be prescribed for immediate relief, and if symptoms persist, a triptan medication may be prescribed for abortive therapy. A follow-up appointment will be scheduled in two weeks to monitor her progress.

References:

Ashina, M., Hansen, J. M., & Do, T. P. (2020). Migraine and the trigeminovascular system-40 years and counting. The Lancet Neurology, 19(9), 719-721.
Buse, D. C., Rupnow, M. F., & Lipton, R. B. (2020). Assessing and managing all aspects of migraine: migraine attacks, migraine-related functional impairment, common comorbidities, and quality of life. Mayo Clinic Proceedings, 95(9S), S27-S49.
Headache Classification Committee of the International Headache Society (IHS) (2021). The International Classification of Headache Disorders, 3rd edition. Cephalalgia, 41(1_suppl), 1-10.
Lipton, R. B., & Silberstein, S. D. (2020). Episodic and chronic migraine headache: breaking down barriers to optimal treatment and prevention. Headache: The Journal of Head and Face