Presenting Complaints

• 41-year-old female patient presents with a chief complaint of recurrent, severe headaches.

History of Presenting Complaint

• The patient reports experiencing these headaches for the past 6 months.
• The headaches typically start in the morning and last throughout the day, with a throbbing, pulsating quality.
• The pain is localized to the right side of the patient's head and is associated with nausea, sensitivity to light, and mild dizziness.
• The headaches occur 2-3 times per week and are often triggered by stress or lack of sleep.
• Over-the-counter pain medications provide some relief, but the headaches often return within a few hours.
• The patient denies any recent head trauma, fever, or changes in vision.

Significant Positives & Negatives For Differentials

Migraine Headache

Positives:

• Unilateral, throbbing headache
• Associated nausea and sensitivity to light
• Triggering factors of stress and lack of sleep
• Family history of migraines

Negatives:

• Lack of fever, vision changes, or other neurological symptoms

Tension-type Headache

Positives:

• Bilateral, non-throbbing headache
• Lack of associated nausea or sensitivity to light
• Potential triggering factors of stress and poor sleep

Negatives:

• Unilateral nature of the headache
• Presence of nausea and dizziness

Cluster Headache

Positives:

• Unilateral, severe, stabbing headache
• Associated with autonomic symptoms (e.g., eye redness, tearing)
• Episodic nature with periods of remission

Negatives:

• Lack of associated nausea or sensitivity to light
• Headaches not occurring in clusters

Secondary Headache (e.g., brain tumor, meningitis)

Positives:

• Presence of neurological symptoms (e.g., vision changes, weakness)
• Lack of response to over-the-counter pain medications

Negatives:

• Absence of fever, vision changes, or other neurological symptoms
• Headaches occurring in a recurrent, episodic pattern

Past Medical History

• The patient has no significant past medical history.
• She reports no previous history of headaches or other neurological conditions.

Drug/Medication History

• The patient takes ibuprofen as needed for her headaches.
• She denies any other regular medication use.

Social History

• The patient is married and works as an accountant.
• She reports high levels of stress at work due to a recent promotion and increased workload.
• The patient denies any history of smoking, alcohol, or recreational drug use.

Family History

• The patient's mother has a history of migraines.
• There is no family history of other neurological disorders.

Systems Review

• Positive for nausea, sensitivity to light, and mild dizziness associated with the headaches.
• Negative for fever, vision changes, weakness, or other neurological symptoms.

Ideas, Concerns & Expectations

• The patient is concerned that the headaches may be a sign of a more serious underlying condition and would like to find an effective treatment to manage the symptoms.

Case Presentation

Based on the patient's history and the significant positives and negatives for the differential diagnoses, the most likely diagnosis is migraine headache. The unilateral, throbbing nature of the headache, associated nausea and sensitivity to light, and triggering factors of stress and lack of sleep are all highly suggestive of a migraine. The patient's family history of migraines also increases the likelihood of this diagnosis. While secondary headaches should always be considered, the lack of fever, vision changes, or other neurological symptoms makes these less likely in this case.