Differential Diagnosis for a 24-year-old Female with Headache and Chest Pain

Single Most Likely Diagnosis

• Anxiety or Panic Attack: The patient's symptoms of headache, chest pain, and anxiety, without any neurologic deficits, could be indicative of a panic attack, especially given her history of migraines and the fact that this episode feels worse. The symptoms of panic attacks can include chest pain, headaches, and a sense of impending doom, which aligns with her presentation.

Other Likely Diagnoses

• Migraine with Aura: Although the patient mentions this headache is worse than her typical migraines, migraines can sometimes present with atypical symptoms, including chest pain, especially if there's an aura phase that involves neurological symptoms not mentioned here but possible.
• Costochondritis: Inflammation of the cartilage that connects the ribs to the breastbone can cause chest pain that might radiate to the head, causing a headache. This condition is relatively common and could explain both symptoms.
• Tension Headache: Stress and anxiety can lead to tension headaches, which might be perceived as worse than usual if the patient is under significant stress or experiencing a panic attack.

Do Not Miss Diagnoses

• Pulmonary Embolism (PE): Although less likely in a young patient without risk factors, PE can present with sudden onset chest pain and could potentially cause a headache due to hypoxia or anxiety related to the pain. Missing this diagnosis could be fatal.
• Aortic Dissection: A tear in the aorta can cause severe chest pain that might radiate to the head, leading to a headache. This condition is life-threatening and requires immediate intervention.
• Myocardial Infarction (MI): While rare in young females without risk factors, MI can present with atypical symptoms, including chest pain and headache. It's crucial to consider this diagnosis to avoid missing a potentially fatal condition.
• Subarachnoid Hemorrhage: A sudden, severe headache (often described as "the worst headache of my life") can be a sign of a subarachnoid hemorrhage, which is a life-threatening condition requiring immediate medical attention.

Rare Diagnoses

• Temporal Arteritis: Although more common in older adults, temporal arteritis can cause headaches and, in rare cases, might be associated with chest pain due to polymyalgia rheumatica, a condition that often co-occurs with temporal arteritis.
• Mitral Valve Prolapse: This condition can cause chest pain and, in some cases, headaches, especially if there's associated anxiety or if the patient experiences palpitations.

Workup and Medication

Given the differential diagnoses, the initial workup should include:

• ECG to rule out MI
• Troponin levels
• D-dimer if PE is suspected
• Chest X-ray
• Blood pressure check
• Complete blood count (CBC) and basic metabolic panel (BMP)
• Consider CT head or MRI if subarachnoid hemorrhage or other neurological conditions are suspected

Medications could include:

• Aspirin or other antiplatelet agents if MI or PE is suspected (after appropriate diagnostic workup)
• Oxygen if the patient shows signs of hypoxia
• Pain management with acetaminophen or NSAIDs for headache and chest pain, considering the patient's symptoms and potential diagnoses
• Anxiolytics if the patient's symptoms are deemed to be primarily anxiety-related

It's essential to tailor the workup and treatment to the patient's specific presentation and evolving diagnosis, considering the need for rapid assessment and intervention for life-threatening conditions.