What is the complete history and physical exam for a 26-year-old patient (y/p) presenting with increasing headache intensity over the past 1-2 months?

From the Guidelines

A comprehensive history and physical exam for a 26-year-old patient with increasing headache intensity over 1-2 months is crucial to determine the underlying cause and guide management, and should include a detailed headache history, complete medical history, and thorough physical and neurological examination.

Key Components of History

• Ask about the headache's onset, location, quality, intensity (on a scale of 1-10), duration, frequency, and any associated symptoms like nausea, vomiting, photophobia, phonophobia, or visual disturbances 1.
• Inquire about aggravating and alleviating factors, including response to over-the-counter medications.
• Document any warning signs such as "worst headache of life," fever, neck stiffness, or neurological deficits.

Medical History and Physical Examination

• Obtain a complete medical history including previous headaches, head trauma, seizures, hypertension, and recent infections.
• Review medications, particularly oral contraceptives, and assess for substance use including caffeine, alcohol, and recreational drugs.
• Family history of migraines or other neurological conditions is important.
• The physical examination should include:
  • Vital signs (particularly blood pressure)
  • A complete neurological exam (mental status, cranial nerves, motor/sensory function, reflexes, coordination, gait)
  • Fundoscopic examination to check for papilledema
  • Palpation of the head and neck for tenderness
  • Assessment of the temporomandibular joint

Red Flags for Neuroimaging

• Red flags warranting immediate neuroimaging include sudden onset, progressively worsening pattern, neurological deficits, systemic symptoms, or onset after age 50 1.
• Other symptoms that may indicate the need for neuroimaging include a rapidly increasing frequency of headaches, a history of syncope, nausea, headache awakening the patient from sleep, a history of dizziness or lack of coordination, and a history of numbness or tingling. This comprehensive approach helps distinguish between primary headache disorders (migraines, tension headaches) and secondary causes that might require urgent intervention, such as intracranial pressure, infection, or vascular abnormalities.

From the Research

History Taking

To complete a history and physical exam for a 26-year-old patient presenting with increasing headache intensity over the past 1-2 months, the following steps should be taken:

• Take a thorough patient history, which is fundamental for the accurate diagnosis and effective management of health conditions 2
• Use a structured but flexible process of gathering relevant information from patients to inform diagnosis and treatment 2
• Employ important communication skills, including active listening, empathetic communication, and cultural sensitivity 2
• Engage the patient in a conversation about their health issues to facilitate their participation and autonomy 2

Headache Classification

• Primary headache disorders are defined as headaches that are unrelated to an underlying medical condition and are categorized into 4 groups: migraine, tension-type headache, trigeminal autonomic cephalalgias, and other primary headache disorders 3
• Secondary headache disorders are defined as headaches due to an underlying medical condition and are classified according to whether they are due to vascular, neoplastic, infectious, or intracranial pressure/volume causes 3
• Patients presenting with headache should be evaluated to determine whether their headache is most likely a primary or a secondary headache disorder 3

Red Flags

• Evaluate patients for symptoms or signs that suggest an urgent medical problem, such as:
  • Abrupt onset
  • Neurologic signs
  • Age 50 years and older
  • Presence of cancer or immunosuppression
  • Provocation by physical activities or postural changes 3

Treatment Options

• Acute migraine treatment includes:
  • Acetaminophen
  • Nonsteroidal anti-inflammatory drugs
  • Combination products that include caffeine 3, 4
• Migraine-specific treatments, such as triptans (5-HT1B/D agonists), can eliminate pain in 20% to 30% of patients by 2 hours, but are accompanied by adverse effects 3
• Gepants, antagonists to receptors for the inflammatory neuropeptide calcitonin gene-related peptide, can eliminate headache symptoms for 2 hours in 20% of patients, but have adverse effects of nausea and dry mouth 3
• Preventive treatments, such as antihypertensives, antiepileptics, antidepressants, calcitonin gene-related peptide monoclonal antibodies, and onabotulinumtoxinA, can reduce migraine by 1 to 3 days per month relative to placebo 3, 5