What is the diagnosis and management for an 18-year-old female with frequent headaches, including migraines and tension-type headaches, with symptoms of eye pressure, and recent prescription glasses, and history of occasional sleep deprivation and stress?

Diagnosis and Management of Mixed Headache Disorder in an 18-Year-Old Female

Primary Diagnosis

This patient most likely has both migraine without aura and tension-type headache (TTH), a common coexistence that affects management and requires recognition of both disorders. 1, 2, 3

The clinical picture reveals features of both headache types:

Migraine Features Present

• Unilateral location ("on one side of the head sometimes") meets one of the required pain characteristics 1, 2
• Duration of three days falls within the 4-72 hour criterion for migraine 1, 2
• Mild nausea and light sensitivity fulfill the associated symptom requirements (photophobia counts even when mild) 1, 2
• Identifiable triggers including sleep deprivation and stress are classic migraine precipitants 1

Tension-Type Headache Features Present

• Bilateral pressure sensation ("circling top of head," "above eyebrows") with pressing/tightening quality is characteristic of TTH 1, 2, 4
• Pressure in eyes and forehead represents the typical band-like distribution 4
• Stress as a trigger is common in TTH 4

Critical Diagnostic Consideration

The coexistence of migraine and TTH in the same patient is extremely common in clinical populations, and applying both diagnoses is appropriate when criteria for each are met separately. 5, 3 Many clinicians mistakenly apply only one diagnosis, which complicates management 5.

Ruling Out Secondary Causes

No red flags are present that would mandate neuroimaging at this time. 2 The patient lacks:

• Thunderclap or "worst headache of life" presentation 2
• Focal neurological deficits 2
• Progressive worsening pattern 2
• Fever or neck stiffness 2
• Headache awakening from sleep 2
• New onset after age 50 (she is 18) 2

The improvement with new prescription glasses suggests a refractive error was contributing but not fully explaining the headaches. 2 This is a common scenario where correcting vision reduces but does not eliminate primary headache disorders.

Diagnostic Confirmation Strategy

Implement Headache Diary Immediately

A headache diary is essential to document attack frequency, duration, character, triggers, and associated symptoms to confirm both diagnoses and guide treatment. 1, 2 The diary should record:

• Days with headache and intensity (0-10 scale) 1, 2
• Location (unilateral vs bilateral) 1, 2
• Quality (throbbing vs pressure) 1, 2
• Associated symptoms (nausea, photophobia, phonophobia) 1, 2
• Medication use (critical for detecting overuse) 1, 2
• Menstrual cycle timing 1
• Sleep patterns and stress levels 1

Consider Screening Instruments

The ID-Migraine questionnaire (sensitivity 0.81, specificity 0.75) can confirm migraine likelihood based on three questions about nausea, photophobia, and disability. 1, 2 However, given the clear clinical picture, formal screening may be less critical than diary documentation.

Acute Treatment Strategy

For Migraine Attacks (Unilateral, Throbbing, with Nausea)

First-line acute treatment should be NSAIDs (ibuprofen 400mg) or aspirin-acetaminophen-caffeine combination for mild-to-moderate attacks. 1 These are appropriate given her age and lack of contraindications.

If NSAIDs fail or attacks are moderate-to-severe, triptans are indicated as migraine-specific therapy. 1 Triptans have good evidence for efficacy and should not be withheld in appropriate candidates 1.

Add an antiemetic (metoclopramide) when nausea is prominent, as it has fair evidence as monotherapy and enhances other treatments. 1

For Tension-Type Headache Attacks (Bilateral, Pressure Quality)

Ibuprofen 400mg or acetaminophen 1000mg are first-line treatments for TTH. 1 These should be used for the bilateral pressure headaches.

Critical Medication-Overuse Warning

Acute medications must be limited to no more than 2 days per week (or 8-10 days per month) to prevent medication-overuse headache. 1, 2 This is a common pitfall where:

• Non-opioid analgesics used ≥15 days/month for ≥3 months cause medication-overuse headache 2
• Triptans or combination analgesics used ≥10 days/month for ≥3 months cause medication-overuse headache 2
• This creates a vicious cycle of increasing headache frequency, often progressing to daily headaches 1

If the headache diary reveals frequent headache days requiring acute medication, preventive therapy becomes mandatory. 1, 2

Preventive Therapy Indications

Preventive therapy should be considered if:

• Headaches occur ≥4 days per month causing disability 1
• Acute medication use approaches 2 days per week 1, 2
• Quality of life is significantly impaired 1

Preventive Options for Migraine

For episodic migraine prevention, evidence-based options include: 1

• Topiramate (has evidence for both episodic and chronic migraine) 1
• Propranolol (well-established efficacy, 20-80mg three times daily showed significant reduction in headache index) 6
• Lisinopril or angiotensin-receptor blockers 1
• Magnesium supplementation 1
• Newer CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab) or oral gepants (atogepant) 1

Propranolol is particularly attractive in this patient given its long track record, favorable safety profile in young patients, and potential benefit for stress-related symptoms. 6

Preventive Options for Chronic TTH

If TTH becomes chronic (≥15 days/month), amitriptyline has the most evidence as prophylactic therapy. 1, 7 However, this is premature without diary documentation of frequency.

Non-Pharmacologic Interventions

Physical therapy or aerobic exercise can be used for both TTH and migraine management. 1 These should be implemented regardless of medication choices.

Biofeedback, relaxation training, and cognitive therapy are commonly employed modalities, though large rigorous trials are lacking. 4 Given her stress and occasional sleep deprivation, these interventions address modifiable triggers.

Sleep hygiene optimization is critical given the identified sleep deprivation trigger. 1 Consistent sleep-wake schedules reduce migraine frequency.

Follow-Up and Monitoring

Re-evaluate in 4-6 weeks with completed headache diary to:

• Confirm diagnoses based on documented attack patterns 1, 2
• Assess acute medication frequency to detect early overuse 1, 2
• Determine need for preventive therapy based on disability and frequency 1
• Adjust treatment based on response 1

Referral to neurology is indicated if: 2

• Diagnosis remains uncertain after diary review 2
• First-line treatments fail 2
• Headache frequency progresses to ≥15 days/month (chronic migraine threshold) 2
• Any red flags develop 2

Common Pitfalls to Avoid

Do not assume all headaches are one type—this patient clearly has features of both migraine and TTH, requiring tailored treatment for each. 5, 3 Rigid adherence to single diagnoses results in suboptimal management 3.

Do not allow unrestricted acute medication use—this is the most common pathway to chronic daily headache in young patients. 1, 2 Set clear limits from the outset.

Do not overlook the vision correction as a contributing factor—while it helped, it did not eliminate the primary headache disorders, which require separate management. 2

Do not miss the opportunity for lifestyle modification—addressing sleep deprivation and stress may reduce headache burden more than any medication. 1, 4