Case Study:

Justine is alert and oriented to self, time, place, and events.  She is a 42-year-old female with a PMH: hypertension, hypothyroidism, history of varicella-zoster as a kid who presents to the clinic with the complaint of burning intermittent headache for the last 3 days.  She denies a history of headaches.  Reports headache on the right side of her head, rating it a three out of ten on the pain scale.  Has tried ibuprofen without relief. Denies changes in vision, photophobia, phonophobia, dizziness, fever, nausea, vomiting, weakness, weight loss/gain, or trauma.  Family history includes a mother who suffered from glioblastoma and a sister who suffers from vestibular migraines.  Justine takes chlorthalidone daily, levothyroxine, and Ethinyl estradiol/norethindrone.  Her last menses was one week ago.  Denies alcohol, illicit drug, or tobacco use.  She reports eating healthy and running for at least 30 minutes every day.  Her last cervical screening was 6 months ago, which showed no abnormal findings.  She has recently been fatigued as the day progresses but attributes it to reducing caffeine use.  Headache does not prevent her from running, and running does not make it worse.  Negative for Lhermitte’s sign.  On examination, negative Brudzinski and Kernig’s sign.  As well as negative pronator drift, HINTS exam, and no focal weakness observed.  The headache was not provoked by touching the face.

This is an unfolding case study we will utilize for the next couple of units.

Questions

1. Based on the information provided at this time, what are your differential diagnoses? How does your unit 2 differential diagnosis list compare to your unit 1 discussion board differential diagnosis list? Were you able to rule in or rule out any diagnoses?
   • Provide support or clinical reasoning based on pertinent positive and negative findings.
2. Evidence-based plan to help rule in or out your differential diagnoses.
3. Does this patient have any red flag symptoms associated with the headache?
4. Pose two open-ended questions for your peers to respond to regarding questions you may have experienced researching the topic or required unit material.

ANSWER

Case Study Analysis: Evaluating a Patient’s Headache Complaint and Differential Diagnoses

Based on the information provided, the following are potential differential diagnoses for Justine’s intermittent headache:

Tension-Type Headache (TTH)
TTH is characterized by bilateral, pressing or tightening headache pain.
Justine’s description of a burning intermittent headache on one side of her head is not consistent with the typical presentation of TTH.

Migraine
Migraines can present with unilateral headache, photophobia, phonophobia, and can be associated with family history.
However, Justine’s headache is not severe (rated 3/10), and she denies nausea, vomiting, or changes in vision.

Cluster Headache
Cluster headaches are severe, unilateral headaches with associated autonomic symptoms.
Justine does not describe the characteristic severe pain or autonomic symptoms like tearing and nasal congestion.

Hypertension-Related Headache
Justine has a history of hypertension, and uncontrolled blood pressure can lead to headaches.
However, her blood pressure is not mentioned in the case, and her headache does not fit the typical pattern of hypertension-related headaches.

Sinusitis
Sinusitis can cause intermittent headaches, often with facial tenderness and nasal congestion.
Justine does not report facial tenderness, and her headache is not provoked by touching her face.

Primary Exercise Headache
Justine is physically active and reports daily running.
Exercise can trigger primary exercise headaches, but these are usually bilateral and throbbing, not burning as described by Justine.

Comparison with Unit 1 Differential Diagnosis

In Unit 1, the initial discussion board differential diagnosis included tension-type headache, migraine, cluster headache, and hypertension-related headache.
In Unit 2, based on additional information, sinusitis and primary exercise headache have been added, and cluster headache has been ruled out based on the absence of severe pain and autonomic symptoms.

Evidence-Based Plan to Rule In or Out Differential Diagnoses

Migraine: Consider conducting a more detailed assessment to rule in or out migraine. This may include asking about potential triggers, aura symptoms, and family history of migraine. If suspicion remains, a trial of migraine-specific medication could be considered.

Sinusitis: Evaluate for signs of sinusitis, such as facial tenderness or nasal congestion. A physical examination of the sinuses may be necessary. If sinusitis is suspected, appropriate antibiotics or decongestants can be prescribed.

Primary Exercise Headache: Inquire about the timing of Justine’s headache in relation to her daily running. Primary exercise headaches often occur during or after exercise. If consistent, further evaluation may be needed.

Red Flag Symptoms

Justine’s headache, as described in the case, does not exhibit any red flag symptoms such as sudden onset, severe intensity, neurological deficits, visual disturbances, or signs of increased intracranial pressure. Therefore, there are no immediate indications of a serious underlying condition.

Open-Ended Questions for Peers

Have you encountered cases of exercise-induced headaches, and what diagnostic and management strategies have you found effective?
What further diagnostic tests or assessments would you recommend to rule in or rule out the remaining potential differential diagnoses for Justine’s headache?