What is the best course of action for a 40-year-old woman experiencing headaches, bloating and gas, and leg pain?

Evaluation and Management of Headache, Bloating/Gas, and Leg Pain in a 40-Year-Old Woman

This 40-year-old woman requires a systematic evaluation starting with ruling out serious causes, particularly ovarian cancer given her age and bloating symptoms, followed by targeted workup for functional gastrointestinal disorders and primary headache syndromes.

Initial Red Flag Assessment

Critical Exclusions in Women Over 40

• Screen for ovarian cancer immediately as bloating and abdominal fullness are often presenting symptoms in women 50 years or older, though risk begins in the 40s 1, 2
• Assess for alarm symptoms including:
  • Weight loss >10% (suggests malabsorption, malignancy, or serious disease) 2
  • Iron-deficiency anemia (mandates celiac disease testing and possible endoscopy) 2
  • Gastrointestinal bleeding (visible blood or black tarry stools) 3
  • Family history of inflammatory bowel disease or colorectal cancer 3

Headache Red Flags Requiring Urgent Evaluation

• New onset or recent change in headache pattern at age 40+ warrants investigation 4, 5
• Assess for:
  • Abrupt onset or "worst headache ever" (suggests subarachnoid hemorrhage) 6
  • Headache with neurologic deficits 4, 5
  • Headache brought on by Valsalva maneuver, cough, or exertion 4
  • Headache that disturbs sleep or changes character 6
  • Associated systemic symptoms (fever, weight loss) 4

Gastrointestinal Workup for Bloating and Gas

First-Line Diagnostic Approach

• Obtain tissue transglutaminase IgA and total IgA levels to screen for celiac disease, particularly if any alarm symptoms present 1, 2
• Consider upper endoscopy in patients over 40 years with dyspeptic symptoms and bloating, especially in regions with high Helicobacter pylori prevalence 1
• Abdominal x-ray may reveal increased stool burden suggesting constipation or pelvic floor disorder 1

Dietary Assessment and Trial

• Inquire about lactose, fructose, and gluten consumption with correlation to symptoms 3
• Implement a 2-week dietary restriction trial targeting:
  • Lactose (affects 51% of bloating patients) 2
  • Fructose (affects 60% of bloating patients) 2
  • FODMAPs or fructans (may be the actual culprit rather than gluten) 1, 2
• Symptom resolution during restriction serves as a positive diagnostic predictor 2

Bowel Habit Characterization

• Use Bristol Stool Scale to assess stool consistency 3
• Ask about:
  • Relationship between bloating and meals 3
  • Constipation, diarrhea, or alternating patterns (suggests IBS) 3
  • Straining with soft stool or need for digital disimpaction (suggests pelvic floor dyssynergia) 1, 3, 2
  • Sensation of incomplete evacuation 3

When to Consider Advanced Testing

• Do not routinely order gastric scintigraphy or wireless motility capsule for bloating alone, as symptoms do not correlate with gastric emptying delay 1, 2
• Reserve motility testing for patients with severe nausea/vomiting, weight loss, or suspected intestinal neuromyopathic disorders 1
• Consider SIBO testing (hydrogen breath test) only in high-risk patients: chronic watery diarrhea, malnutrition, weight loss, or systemic diseases causing dysmotility (cystic fibrosis, Parkinson disease) 1, 2

Headache Management

Acute Treatment

• First-line: Acetaminophen 1000 mg for acute headache episodes 5
• Second-line options if acetaminophen fails:
  • NSAIDs (ibuprofen) combined with caffeine for additional benefit 5
  • Triptans (5-HT1B/D agonists) eliminate pain in 20-30% by 2 hours, but avoid in cardiovascular disease due to vasoconstrictive properties 5
  • Gepants (rimegepant, ubrogepant) eliminate headache in 20% at 2 hours with nausea/dry mouth in 1-4% 5

Preventive Therapy Indications

• Consider if ≥2 attacks per month producing disability for ≥3 days 7
• Consider if using acute medication >2 times per week 7
• Avoid medication overuse: limit triptans to <10 days/month, acetaminophen/NSAIDs to <15 days/month 7, 5

Lifestyle Modifications

• Maintain adequate hydration, regular meals, consistent sleep patterns 7
• Identify and avoid specific migraine triggers 7
• Consider biofeedback, relaxation techniques, massage, ice packs 7

Leg Pain Evaluation

The provided evidence does not specifically address leg pain evaluation. Based on general medical knowledge, assess for:

• Deep vein thrombosis risk factors (especially with bloating suggesting possible pelvic mass)
• Peripheral vascular disease
• Musculoskeletal causes
• Neurologic causes (radiculopathy)

Treatment Algorithm for Bloating

1. Rule out ovarian cancer with pelvic examination and imaging if indicated 1, 2
2. Screen for celiac disease with serology 1, 2
3. Trial 2-week dietary restriction of lactose, fructose, and FODMAPs 2
4. If symptoms persist, consider functional diagnosis (IBS, functional bloating) and treat symptomatically 2
5. Simethicone can be used for symptomatic relief of gas-related pressure and bloating 8

Common Pitfalls to Avoid

• Do not miss ovarian cancer in women approaching 50, as bloating is often the presenting symptom 1, 2
• Do not assume gastroparesis based on bloating and nausea alone without severe vomiting, as symptoms don't correlate with gastric emptying delay 1, 2
• Do not ignore pelvic floor dysfunction: straining with soft stool suggests dyssynergia, not simple constipation 1, 2
• Do not overlook medication history: many commonly used drugs cause constipation and bloating 3
• Do not dismiss new headache at age 40+ without proper evaluation for secondary causes 4, 5