What is the complete history and physical examination of a 26-year-old (y/o) patient presenting with increasing intensity of headaches for 1-2 months?

From the Guidelines

A comprehensive history and physical exam for a 26-year-old with worsening headaches over 1-2 months is crucial to distinguish between primary headache disorders and secondary causes that might require urgent attention. This approach should begin with a detailed headache history, including onset, location, quality, intensity (using a 0-10 scale), duration, frequency, and exacerbating/alleviating factors, as suggested by the International Headache Society Classification of Headaches 1. Ask about associated symptoms like nausea, vomiting, visual changes, photophobia, phonophobia, neck stiffness, fever, or neurological deficits. Document any aura, warning signs, or pattern changes. Inquire about triggers such as stress, certain foods, alcohol, caffeine, sleep disturbances, or menstrual cycles. Obtain a complete medical history including previous headaches, head trauma, recent infections, hypertension, and family history of migraines or neurological disorders. Review current medications, including over-the-counter drugs and supplements. Assess psychosocial factors like recent life stressors, anxiety, or depression.

The physical examination should include:

• Vital signs (particularly blood pressure)
• A complete neurological exam (cranial nerves, motor/sensory function, reflexes, coordination, gait)
• Fundoscopic exam to check for papilledema
• Head and neck examination for tenderness or masses
• Assessment of sinuses and temporomandibular joints This thorough approach is supported by recent guidelines on the diagnosis and management of migraine, which emphasize the importance of a systematic medical history and physical examination in diagnosing migraine 1. Further investigations, such as neuroimaging, may be required to confirm or reject suspicions of secondary causes for headache, but should be considered only in patients with atypical headache patterns or neurologic signs, as suggested by the American Academy of Neurology and the U.S. Headache Consortium 1.

From the Research

History of Present Illness

• A complete history of the patient's headaches is essential, including the duration, frequency, severity, and any triggers or relieving factors 2
• The patient's symptoms have been increasing in intensity over the past 1-2 months, which may indicate a progressive condition
• It is crucial to ask about any associated symptoms, such as nausea, vomiting, photophobia, or phonophobia, to help guide the diagnosis and treatment

Past Medical History

• A thorough past medical history is necessary to identify any potential underlying conditions that may be contributing to the patient's headaches
• The patient's medical history, including any previous diagnoses, medications, and allergies, should be reviewed to help inform the diagnosis and treatment plan 3

Physical Examination

• A comprehensive physical examination is essential to help identify any potential causes of the patient's headaches
• The physical examination should include a thorough neurological examination, including an assessment of the patient's mental status, cranial nerves, and motor and sensory function 3
• The patient's vital signs, including blood pressure, pulse, and temperature, should also be monitored to help identify any potential underlying conditions

Diagnostic Considerations

• Based on the patient's symptoms, migraine is a potential diagnosis, and treatment options such as acetaminophen, nonsteroidal anti-inflammatory drugs, and triptans may be considered 4, 5
• The patient's response to treatment and any associated symptoms will help guide the diagnosis and treatment plan
• Further diagnostic testing, such as imaging or laboratory studies, may be necessary to rule out other potential causes of the patient's headaches 2

Treatment Options

• Acetaminophen and nonsteroidal anti-inflammatory drugs are first-line treatments for mild to moderate migraines, while triptans are first-line treatments for moderate to severe migraines 4, 5
• The addition of an antiemetic, such as metoclopramide, may be beneficial in reducing nausea and vomiting associated with migraines 6
• The patient's treatment plan should be individualized based on their specific symptoms, medical history, and response to treatment 4, 5