Write a SOAP note for a 45-year-old female who has bilateral dull pressure headaches on awakening twice weekly, without nausea, vomiting, visual changes, or other red‑flag symptoms.

SOAP Note: 45-Year-Old Female with Morning Headaches

Subjective

Chief Complaint: Headache upon awakening twice weekly

History of Present Illness:

• 45-year-old female reports bilateral, dull, pressure-type headaches occurring specifically on awakening
• Frequency: 2 times per week
• Duration: [Document specific duration when headache resolves]
• Character: Dull, pressure sensation, bilateral
• Critical negatives to document:
  • No nausea or vomiting
  • No visual changes or photophobia
  • No focal neurological symptoms
  • No autonomic symptoms (lacrimation, rhinorrhea, ptosis)
  • Headache behavior with activity/position changes
  • Time of night when awakening occurs (if mid-sleep vs. early morning)
  • Any motor activity during headache (getting up, walking around)
  • Response to over-the-counter medications

Red Flag Assessment (must document absence of): 1

• No recent head/neck trauma
• No "worst headache of life" or thunderclap onset
• No personality changes
• No fever, weight loss, or systemic symptoms
• No immunocompromised state
• No worsening with Valsalva/exertion/cough

Past Medical History:

• Document any history of hypertension (morning headaches can indicate nocturnal hypertension)
• Prior headache history
• Sleep disorders, including sleep apnea
• Medication overuse patterns

Social History:

• Caffeine intake timing and amount
• Sleep hygiene and schedule
• Stress factors

Objective

Vital Signs:

• Blood pressure (critical - check for hypertension)
• Heart rate, respiratory rate, temperature

Neurological Examination:

• Mental status: Alert, oriented x3
• Cranial nerves II-XII: Intact, specifically:
  • Visual fields full
  • Pupils equal, round, reactive to light
  • No papilledema on fundoscopic exam (critical to rule out elevated intracranial pressure)
  • Extraocular movements intact
• Motor: 5/5 strength all extremities, normal tone
• Sensory: Intact to light touch and pinprick
• Reflexes: 2+ and symmetric
• Coordination: Finger-to-nose and heel-to-shin intact
• Gait: Normal
• Neck: Supple, no meningismus, no nuchal rigidity

General Examination:

• No temporal artery tenderness or prominence (rule out temporal arteritis, though age makes this less likely)

Assessment

Most likely diagnosis: Tension-type headache (TTH) - The bilateral, dull, pressure quality with twice-weekly frequency and absence of associated symptoms is most consistent with episodic TTH 2.

Differential diagnoses to consider:

1. Tension-Type Headache (Primary consideration)

   • Bilateral pressure quality fits classic presentation
   • Frequency <15 days/month = episodic TTH
   • No associated autonomic or migrainous features 2

2. Sleep-related hypertension

   • Morning headaches can indicate nocturnal blood pressure elevation
   • Requires 24-hour ambulatory BP monitoring if suspected 3

3. Hypnic headache (less likely given age)

   • Typically affects patients >55 years old 4, 5, 6
   • Would expect more frequent attacks (often nightly)
   • Patient is younger than typical presentation

4. Medication overuse headache

   • Document analgesic use frequency

5. Sleep apnea-related headache

   • Consider if snoring, witnessed apneas, daytime somnolence present

Diagnostic workup needed:

• No neuroimaging indicated at this time - Patient lacks red flag symptoms that would warrant MRI or CT 1
• 24-hour ambulatory blood pressure monitoring if office BP elevated or clinical suspicion for nocturnal hypertension 3
• Sleep study if clinical features suggest sleep apnea

Plan

Acute Treatment

For active headache episodes: 2

• Ibuprofen 400 mg at headache onset (first-line for TTH)
• Alternative: Acetaminophen 1000 mg at headache onset
• Avoid using acute medications >2 days per week to prevent medication overuse headache

Prophylactic Treatment

If headaches persist or worsen despite acute treatment: 2

• Amitriptyline 10-25 mg at bedtime, titrate up to 50-75 mg as needed for chronic TTH prevention
• This is particularly appropriate given nocturnal timing

Non-Pharmacological Interventions

Strongly recommend: 2

• Physical therapy focusing on cervical and shoulder girdle
• Aerobic exercise 30 minutes, 3-5 times weekly
• Sleep hygiene optimization:
  • Consistent sleep/wake schedule
  • Avoid caffeine after 2 PM
  • Evaluate pillow support and sleep position

Monitoring and Follow-up

• Headache diary for 4 weeks documenting:

  • Frequency, duration, severity (0-10 scale)
  • Associated symptoms
  • Medication use and response
  • Sleep quality and timing

• Return visit in 4 weeks to:

  • Review headache diary
  • Reassess for any new red flag symptoms
  • Adjust treatment based on response
  • Consider prophylactic therapy if frequency increases

Patient Education

• Return immediately or go to ED if:
  • Sudden severe "thunderclap" headache
  • Headache with fever, stiff neck, confusion
  • New focal neurological symptoms (weakness, vision changes, speech difficulty)
  • Headache after head trauma
  • Worst headache of life

Common pitfall to avoid: Morning headaches that awaken from sleep warrant blood pressure evaluation, as they can indicate nocturnal hypertension - ensure BP is checked and consider 24-hour monitoring if elevated 3.