What are the next steps and possible diagnosis for a 24-year-old female (F) patient with a chief complaint of headache, originating in the glabellar area and radiating to the frontal sinuses, accompanied by a sensation of 'earthquake', relieved by sniffing a white flower, resting, and lowering computer monitor brightness, with a history of allergy to shrimp and physical examination findings of white, feather-like lesions on the tympanic membranes and otherwise normal hearing?

Headache in a 24-Year-Old Female: Next Steps and Diagnosis

Most Likely Diagnosis

This presentation is most consistent with migraine without aura, specifically triggered by prolonged screen exposure, though the tympanic membrane findings require separate evaluation as they are unrelated to the headache. 1

Clinical Reasoning

Primary Headache Features Supporting Migraine

• Glabellar/frontal location with radiation to frontal sinuses is consistent with migraine distribution 1
• Duration of 1 hour with recurrence 3-4 hours later fits migraine attack patterns 1
• Relief with rest and reducing screen brightness suggests photophobia, a cardinal migraine feature 1
• Relief with aromatic inhalation (white flower) may represent a behavioral coping mechanism or placebo effect common in migraine 1
• "Earthquake" sensation likely represents a non-specific dizziness or vertigo that can accompany migraine attacks 1

Red Flags Assessment - NONE PRESENT

No neuroimaging is indicated in this case because the patient lacks any red flags for secondary headache 1, 2, 3:

• No thunderclap onset 3
• No "worst headache of life" 3
• No fever, neck stiffness, or focal neurological deficits 3
• No altered consciousness or personality changes 3
• Age <50 years 3
• No progressive worsening pattern 3
• Normal neurologic examination (aside from incidental tympanic findings) 1, 2

Tympanic Membrane Findings - Separate Issue

The white, feather-like lesions on bilateral tympanic membranes are consistent with tympanosclerosis or myringosclerosis, which are benign sequelae of prior middle ear inflammation or trauma and are completely unrelated to her headache complaint [@general medical knowledge]. These require no acute intervention but ENT follow-up may be considered if hearing changes develop.

Immediate Next Steps

1. Confirm Migraine Diagnosis

Use validated screening tools rather than extensive testing [1, @8@]:

• Apply the ID-Migraine questionnaire (3 questions: photophobia, nausea, disability from headache - sensitivity 0.81, specificity 0.75) [@4@, 2]
• Initiate a headache diary to document frequency, duration, associated symptoms, and triggers over 4 weeks [1, @8@]
• Ask specifically: "Do you have headache on 15 or more days per month?" to screen for chronic migraine [@1@]

2. Screen for Medication Overuse

Obtain detailed medication history including over-the-counter analgesics to exclude medication overuse headache, which can complicate migraine [@11@]. Ask about:

• Frequency of analgesic use (>10 days/month for triptans, >15 days/month for simple analgesics suggests overuse) 4
• Use of medications obtained from others [@11@]

3. Identify Modifiable Triggers

Screen exposure is clearly a trigger in this patient [@1@]:

• Recommend scheduled screen breaks every 20-30 minutes [@general medical knowledge]
• Optimize screen brightness and blue light filtering [@general medical knowledge]
• Assess for other common triggers: sleep quality, stress, caffeine intake [@1@, @6@]

Treatment Plan

Acute Treatment

Start with NSAIDs as first-line therapy [@6@]:

• Ibuprofen 400-800mg or diclofenac potassium 50-100mg at headache onset when pain is still mild [@6@]
• Avoid acetylsalicylic acid given shrimp allergy (cross-reactivity concern with salicylates in some shellfish-allergic patients) [@general medical knowledge]

If NSAIDs provide inadequate relief after 2-3 attacks, advance to triptan therapy 1:

• Triptans are most effective when taken early during mild pain phase 1
• Multiple triptans available; if one fails, others may still work 1

Preventive Therapy Consideration

Preventive therapy is NOT yet indicated because:

• Patient does not meet criteria for chronic migraine (<15 headache days/month) 1
• Frequency appears episodic based on history 1
• Reassess need for prevention if headache diary shows ≥4 attacks per month or significant disability 1

Common Pitfalls to Avoid

• Do not order neuroimaging without red flags - this exposes patients to unnecessary radiation, cost, and anxiety from incidental findings 1, 2
• Do not conflate the tympanic findings with headache etiology - these are separate, unrelated findings [@general medical knowledge]
• Do not delay triptan therapy if NSAIDs fail - many migraine patients remain undertreated 1
• Do not assume attempted ophthalmology consultation was appropriate - visual symptoms during migraine do not require ophthalmologic evaluation unless persistent between attacks [@4@]

Follow-Up Plan

• Schedule return visit in 4-6 weeks with completed headache diary [@4@]
• Reassess diagnosis and treatment response at that time 1
• Consider ENT referral for tympanic findings only if hearing changes develop [@general medical knowledge]