Presenting Complaints

• 43-year-old female patient presents with a chief complaint of persistent headache.

History of Presenting Complaint

• Patient reports a severe, throbbing headache that started 3 days ago.
• The headache is localized to the right side of her head and is associated with nausea and sensitivity to light.
• She describes the pain as an 8/10 in intensity, with the headache worsening throughout the day.
• The patient states that the headache is not relieved by over-the-counter pain medication.
• She denies any recent head trauma, fever, or changes in vision.

Significant Positives & Negatives For Differentials

Migraine

Positives:

• Unilateral, throbbing headache
• Associated nausea and photophobia
• Lack of response to over-the-counter pain medication
• Family history of migraines

Negatives:

• Sudden onset of severe headache
• Presence of fever, chills, or neck stiffness
• Changes in vision or hearing

Tension-type Headache

Positives:

• Bilateral, non-throbbing headache
• Lack of associated nausea or photophobia
• Responsive to over-the-counter pain medication

Negatives:

• Unilateral location of headache
• Severe intensity of headache (8/10)
• Lack of improvement with medication

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 photophobia
• Absence of circadian rhythm in headache pattern
• No history of previous cluster headache episodes

Brain Tumor

Positives:

• Severe, persistent headache
• Lack of response to pain medication
• Potential for associated neurological symptoms (e.g., vision changes, motor/sensory deficits)

Negatives:

• Absence of other neurological symptoms
• Normal vital signs
• No history of head trauma

Subarachnoid Hemorrhage

Positives:

• Sudden onset of severe headache
• Associated with neck stiffness or altered mental status
• Potential for neurological deficits

Negatives:

• Lack of history of head trauma
• Normal vital signs
• Absence of neck stiffness or changes in vision/hearing

Past Medical History

• Hypertension, well-controlled on lisinopril
• No history of migraines or other chronic headache disorders

Drug/Medication History

• Lisinopril 10 mg daily

Social History

• Married, works as an accountant
• Non-smoker, occasional social drinker
• Denies any recreational drug use

Family History

• Father had a history of migraines
• No family history of brain tumors or other neurological disorders

Systems Review

• Positive for nausea and photophobia
• Negative for fever, chills, neck stiffness, or changes in vision or hearing

Ideas, Concerns & Expectations

• Patient is concerned that the headache may be a sign of a more serious underlying condition, such as a brain tumor.

Case Presentation

The initial diagnosis that the student should arrive at is a primary headache disorder, most likely migraine. The key features supporting this diagnosis include the unilateral, throbbing nature of the headache, associated nausea and photophobia, and lack of response to over-the-counter pain medication. The absence of other neurological symptoms, normal vital signs, and lack of recent head trauma help rule out more serious conditions like brain tumor or subarachnoid hemorrhage.