A 28-year-old female presents with a severe headache for the past 9 hours. She states the pain is over the left temporal area and is throbbing in nature. These symptoms have occurred before but not as bad.

A 28-year-old female presents with a severe headache for the past 9 hours. She states the pain is over the left temporal area and is throbbing in nature. These symptoms have occurred before but not as bad.

A 28-year-old female presents with a severe headache for the past 9 hours. She states the pain is over the left temporal area and is throbbing in nature. These symptoms have occurred before but not as bad.

The case study is about a 28-year-old female who presents with a severe headache for the past 9 hours. The pain is throbbing in nature and over the temporal area. This discussion will use the SOAP format to explore the potential history and physical exam elements, differential diagnosis, further testing, and treatment plan.

Subjective

For this case, an inquiry on the triggering situations including alcohol use, certain foods (chocolate, cheese), hunger, frequency of appearance of the headache, the moment of the day when the pain appears, its relationship to sleep, the systemic symptoms associated with the headache including nausea, vomiting, photophobia, and phonophobia and the evolvement of the headache since the onset would be important. Moreover, it is also necessary to know what aggravates or exacerbates the headache including the medications that make it better, and the frequency at which the patient takes medication to achieve pain relief and physical activity respectively (Pescador Ruschel & De Jesus, 2022).

BUY A CUSTOM PAPER HERE

Objective

The physical examination of this case includes the general appearance of the patient whether restless or calm in a dark room, and the determination of the vital signs, including temperature, blood pressure, pulse rate, and respiratory rate. A focus on the head, ear, eye, and neck follows and it involves examining the scalp for areas of swelling and tenderness, palpating the ipsilateral temporal artery and both temporomandibular joints for tenderness and crepitation while the patient opens and closes the jaw.  The eyes and periorbital area are inspected for lacrimation, flushing, and conjunctival injection. Pupillary size and light responses, extraocular movements, and visual fields are also assessed. The ears and nares are inspected for abnormal discharges and ultimately the neck is flexed to detect discomfort or stiffness. The cervical spine is palpated for tenderness (Robbins, 2021). A full neurological examination is then conducted including mental status, cranial nerves, sensory and motor systems, reflexes, gait, stance, and coordination.

Assessment

The diagnosis of this case is made on clinical grounds and it is no coincidence that this case classically presents with the clinical features pointing towards migraine headache without aura, as evidenced by the age, female gender, a 9-hour duration of severe unilateral headache that is throbbing in nature associated with nausea and photophobia and worsened by physical activity but without a preceding focal neurological deficit (aura) (Pescador Ruschel & De Jesus, 2022). The differential diagnoses of this condition include; migraine headache with aura, tension headache, and cluster headache largely because they have similar associations with migraine headache without aura including accompaniment with nausea and vomiting and aggravation by physical activity and temporal arteritis due to the location of headache over the temporal area and its severity.

Plan

The management of this condition includes lifestyle modifications which considerably include avoiding the triggers that include alcohol, caffeine, red wine, chocolate, and cheese and, ensuring good sleep hygiene. The medical therapy largely involves the use of abortive medications first line either being acetaminophen 1000mg PO every 6 hours as needed and the second line being triptans (sumatriptan-naproxen) 85mg-500mg PO once and may be repeated after 2 hours as needed (Burch & Rayhill, 2021). They are effective in aborting migraines if given early enough in the course of an attack; ideally given within 30 minutes of developing a headache, but they may still benefit up to 3 hours after the onset of headache. However, triptans should be avoided in patients with cardiovascular or cerebrovascular disease and in those who are taking monoamine oxidase inhibitors. Lastly, monthly follow-up and health education on the triggers and appropriate and timely intake of medications are paramount to prevent frequent and future attacks.

References

Burch, R., & Rayhill, M. (2021). Acute treatment for migraine: Contemporary treatments and future directions: Contemporary treatments and future directions. JAMA: The Journal of the American Medical Association, 325(23), 2346–2347. https://doi.org/10.1001/jama.2021.7275

Pescador Ruschel, M. A., & De Jesus, O. (2022). Migraine Headache. In StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK560787/

Robbins, M. S. (2021). Diagnosis and management of headache: A review: A review. JAMA: The Journal of the American Medical Association, 325(18), 1874–1885. https://doi.org/10.1001/jama.2021.1640

ORDER A PLAGIARISM-FREE PAPER HERE

A 28-year-old female presents with a severe headache for the past 9 hours. She states the pain is over the left temporal area and is throbbing in nature. These symptoms have occurred before but not as bad.

Differential diagnosis- Migraine without aura.
For the case you have chosen, post to the discussion:

Discuss what questions you would ask the patient, what physical exam elements you would include, and what further testing you would want to have performed.
In SOAP format, list:
Pertinent positive and negative information (common)
Differential and working diagnosis. This headache is unilateral and throbbing and most often accompanied by nausea, photophobia and exacerbation from physical activity.
Migraine with aura (classic)
Treatment plan, including pharmacotherapy with complementary and OTC therapy, diagnostics (labs and testing), health education and lifestyle changes, age-appropriate preventive care, and follow-up to this visit.