Musculoskeletal Pain with Possible Pyelonephritis
This patient requires urgent evaluation for pyelonephritis given the positive CVA tenderness, and the musculoskeletal pain should be treated with NSAIDs while ruling out serious secondary causes. 1
Immediate Diagnostic Priorities
The positive CVA (costovertebral angle) tenderness is a red flag that demands urgent evaluation for pyelonephritis or other renal pathology, not cervical vertebral artery issues as the expanded question suggests. 2, 3 This finding, combined with recent systemic symptoms (headache, sore throat, body pain), raises concern for:
- Acute pyelonephritis - CVA tenderness is the classic physical exam finding, and the 3-day prodrome of systemic symptoms fits this diagnosis 2
- Urinalysis with culture and complete blood count should be obtained immediately to evaluate for infection 3
- Fever assessment is critical - if present with CVA tenderness, this constitutes a medical urgency requiring same-day treatment 2
Evaluation of the Headache Component
The headache pattern (temple to back of head) with associated sore throat suggests either:
- Tension-type headache - bilateral, pressing quality, no aggravation by routine activity 4
- Secondary headache from systemic infection - if pyelonephritis is confirmed 3
Red flags are absent (no thunderclap onset, no neurologic deficits, age <50, no cancer history), making primary headache disorder most likely if infection is ruled out. 5, 2
Acute Treatment Recommendations
For Musculoskeletal Pain (Scapula/Shoulder Tenderness)
Ibuprofen 400-600 mg every 6 hours as needed is first-line treatment for musculoskeletal pain, with maximum use limited to 2 days per week to prevent medication-overuse headache. 1, 6
- Naproxen 500 mg twice daily is an alternative with longer duration of action, particularly useful for inflammatory musculoskeletal conditions 1
- Limit NSAID use to no more than 2 days per week to prevent medication-overuse headache 1
- NSAIDs should be used cautiously if renal impairment is discovered, and avoided entirely if creatinine clearance <30 mL/min 6
For Headache
If the headache persists after treating any underlying infection, ibuprofen 400-600 mg or naproxen 500 mg at headache onset is recommended as first-line therapy. 1, 7
- Acetaminophen 1000 mg is an alternative if NSAIDs are contraindicated, though evidence for tension-type headache is weaker 7
- The combination of aspirin 500 mg + acetaminophen 500 mg + caffeine 130 mg has strong evidence for migraine if the headache proves to be migrainous rather than tension-type 7, 1
Critical Pitfalls to Avoid
Do not dismiss the CVA tenderness as a musculoskeletal finding - this is a specific sign for renal pathology that requires workup even in the absence of dysuria or urinary frequency. 2, 3
Avoid prescribing opioids for this presentation - they carry high risk for dependency and medication-overuse headache, and are inappropriate for both musculoskeletal pain and primary headache disorders. 7, 1
Do not allow the patient to use analgesics more than 2 days per week - frequent use (>2 days/week) paradoxically worsens headache frequency and can lead to chronic daily headache through medication-overuse headache. 1
When to Escalate Care
Immediate emergency department referral is warranted if:
- Fever is present with CVA tenderness (suggests acute pyelonephritis requiring IV antibiotics) 2
- Neurologic deficits develop 5, 2
- Headache becomes thunderclap in onset or progressively worsens 5, 2
Non-emergent neurology referral should be considered if:
- Headaches persist despite treatment and occur more than 2 days per week, warranting preventive therapy evaluation 1
- Headache pattern changes or becomes refractory to first-line treatments 2
Follow-Up Plan
If urinalysis is negative and symptoms persist beyond 1 week, consider physical therapy evaluation for the shoulder/scapular pain and reassess headache pattern to determine if preventive therapy is needed. 1
If headaches continue to occur more than 2 days per week after acute issues resolve, initiate preventive therapy with amitriptyline 30-150 mg/day for tension-type headache or propranolol 80-240 mg/day if migraine is diagnosed. 7, 1