Student version of discussion cases: Headache

Learning Objectives:

• Classify headaches as primary (migraine, tension, cluster, or miscellaneous) or secondary.
• Identify potential red-flag symptoms.
• Know basic treatment modalities for migraine, tension, and cluster headaches.

Suggested Reading:

Clinch CR. Evaluation of Acute Headaches in Adults, American Family Physician, 2001;63:685-692. May be found at: http://www.aafp.org/afp/20010215/685.html

Fogarty JP. Headache (Chapter 34). In: Sloan PD, Slatt LM, Ebell MH, Jacques LB, eds. Essentials of Family Medicine, 4th ed. Philadelphia, PA: Lippincott, Williams and Wilkins, 2002, 547 - 562. Note: This is the required text for the FM Preceptorship.

Case 1:

Sara is a 14-year-old white female in 9th grade who comes to see you because of headaches and nausea occurring about once per month just prior to her menses. These are throbbing in nature and usually most prominent in the left frontal region. She often feels a stabbing type pain behind the left eye. There are no aura-like symptoms, but she has photophobia. When she gets these headaches, she often needs to leave school. She finds that sleeping in a dark quiet room helps. She has tried Tylenol 325 mg or Ibuprofen 200 mg without success. On further questioning, you find that she feels that she doesn't have many friends at school and that she is not involved in school activities. She denies smoking and alcohol use. PE is unremarkable.

Question 1: What type of headache do you think this is? What symptoms support this diagnosis? 

Question 2: What suggestions would you make regarding treatment? 

Question 3: Does this patient have any "red flag" symptoms? What symptoms, if they occurred, would raise the possibility of a more serious or life-threatening condition? 

Question 4: If her headaches became more frequent, how might you consider preventing them? 

Case 2:

Mike is a 29 year old white male businessman who comes in with a history of headaches occurring 2 to 3 times each week for the past several months. He has tried a variety of over-the-counter agents including Tylenol 650 mg every 4 hours, Ibuprofen 800 mg every 4-6 hours, and Naprosyn 500 mg twice a day with some success. However, he feels his headaches have increased in intensity since beginning his new job several months ago. He describes these as bilateral and constant, like a tight band around the head. There is no associated blurry or double vision, photo - or phonophobia, or other neurologic symptoms. Headaches are exacerbated by deadlines at work. They do not awaken him from sleep. He drinks 3-4 cups of coffee daily, does not smoke, and has 2 beers on the weekend. He does not exercise.

Question 1: What type of headache do you think this is? What symptoms support your diagnosis?

Question 2: What suggestions would you make regarding treatment?