Discharge When Improved
For this 35-year-old man with gradual onset, diffuse, throbbing headache who has normal vitals, normal neurological exam, and has improved with non-opioid analgesics, discharge is appropriate without further testing. 1
Clinical Reasoning
This presentation lacks red flags requiring neuroimaging or further workup:
- No thunderclap onset - The headache had gradual onset over hours, not the instantly peaking pain characteristic of subarachnoid hemorrhage 2
- Normal neurological examination - Rules out focal deficits suggesting structural lesions 2
- No meningeal signs - Absence of neck stiffness or fever makes meningitis unlikely 2
- Response to simple analgesics - Improvement with non-opioid medications (acetaminophen or ibuprofen) supports a benign primary headache disorder 1, 3
Why Other Options Are Not Indicated
CT angiogram and CT head without contrast are not warranted because neuroimaging is only mandatory when red flags are present, such as new onset headache with abnormal neurological findings, thunderclap onset, or concerning features suggesting secondary causes like subarachnoid hemorrhage or intracranial mass 2. This patient has none of these features.
Lumbar puncture would only be considered if subarachnoid hemorrhage was suspected (typically with sudden, severe "worst headache of life" presentation) and CT was negative 2. This patient's gradual onset and improvement with simple analgesics makes this unnecessary.
Discharge Instructions
Upon discharge, counsel the patient to:
- Limit acute medication use to no more than twice weekly to prevent medication-overuse headache, which can paradoxically increase headache frequency and lead to daily headaches 1
- Return immediately if headache becomes suddenly severe, is associated with fever/neck stiffness, neurological symptoms develop, or if the pattern changes significantly 2
- Consider preventive therapy if headaches occur more than 2-3 times per week, as this indicates need for prophylactic treatment rather than relying on acute management 1
Common Pitfall to Avoid
Do not order neuroimaging simply because the patient is concerned or "just to be safe" when clinical features are reassuring. Overuse of imaging in low-risk headache patients leads to unnecessary radiation exposure, cost, and potential false-positive findings that trigger additional unnecessary testing 2.