From the Guidelines
For a 26-year-old female presenting with headaches for 1-2 months, I would conduct a comprehensive history and physical examination to determine the cause and appropriate treatment, prioritizing the identification of red flags and the application of the ICHD-3 criteria, as recommended by the most recent and highest quality study 1. The history should begin with detailed questions about the headache characteristics:
- onset
- location
- quality
- severity (using a 0-10 scale)
- duration
- frequency
- and pattern of progression, as outlined in the diagnosis and management of migraine in ten steps 1. I would ask about aggravating and alleviating factors, including response to over-the-counter medications. Associated symptoms are crucial to identify, particularly
- visual disturbances
- nausea
- vomiting
- photophobia
- phonophobia
- neck stiffness
- fever
- or neurological symptoms like weakness, numbness, or speech changes. The patient's medical history should be reviewed, focusing on
- previous headaches
- trauma
- hypertension
- recent infections
- and any history of migraines or other neurological conditions, as suggested by the best practices for patients with chronic migraine 1. Family history of migraines or other headache disorders is relevant. Social history should include
- stress levels
- sleep patterns
- caffeine intake
- alcohol consumption
- and substance use. Medication history, including oral contraceptives, is important as some medications can cause headaches. For the physical examination, I would check vital signs (particularly blood pressure), conduct a thorough neurological examination including
- cranial nerves
- motor strength
- sensation
- reflexes
- coordination
- and gait. I would examine the head and neck for tenderness, perform fundoscopy to check for papilledema, and assess for meningeal signs, as recommended by the management of the acute migraine headache 1. Depending on the findings, further investigations might include neuroimaging or laboratory tests to rule out secondary causes of headache, following the guidelines outlined by the U.S. Headache Consortium 1.
From the Research
History of Presenting Complaint
To evaluate a 26-year-old female presenting with headaches for 1-2 months, it is essential to take a comprehensive history of the presenting complaint. This includes:
- Duration and frequency of headaches
- Characteristics of the headache, such as location, severity, and quality of pain
- Triggers or factors that exacerbate or relieve the headache
- Associated symptoms, such as nausea, vomiting, photophobia, or phonophobia
- Impact of headaches on daily activities and quality of life
Past Medical History
It is also crucial to inquire about the patient's past medical history, including:
- Previous episodes of headache or migraine
- Other medical conditions, such as hypertension, diabetes, or cancer
- History of trauma or injury to the head or neck
- Current medications or supplements that may be contributing to the headaches
Family History
A family history of headache or migraine can also be relevant, as it may indicate a genetic predisposition to these conditions.
Red Flags
When evaluating a patient with headaches, it is essential to identify red flags that may indicate a more serious underlying condition, such as:
- Sudden onset or severe headache
- Headache accompanied by fever, stiff neck, or confusion
- Headache that worsens over time or is exacerbated by coughing, sneezing, or straining
- Headache that is accompanied by neurological symptoms, such as weakness, numbness, or tingling
Physical Exam
A thorough physical exam is also necessary to evaluate the patient's overall health and identify any potential causes of the headaches. This may include:
- Vital signs, such as blood pressure and temperature
- Neurological exam, including assessment of mental status, cranial nerves, and motor and sensory function
- Examination of the head and neck, including palpation of the scalp and neck muscles
According to 2, primary headache disorders, such as migraine and tension-type headache, are common and can be debilitating. A thorough history and physical exam are essential to diagnose and manage these conditions effectively. The American Headache Society recommends a stratified approach to treating acute migraine, with first-line treatments including acetaminophen, nonsteroidal anti-inflammatory drugs, and triptans 3. Other studies have also emphasized the importance of individualizing treatment based on the pattern and severity of attacks 4, 5. Additionally, nonpharmacologic interventions and neuromodulation may also be effective in managing migraine and tension-type headache 5, 6.