Onset:
Context during onset: non-exertional
History of trauma at any time surrounding onset of headache: No
Time from onset to maximal severity:
Previous treatment trying: Tylenol
Maximal severity per patient: 10/10
History of headaches in the past: Yes patient states she’s had headaches approximately every month for the past 9 months.
History of prior headaches:
Frequency of headaches at baseline:
Quality of headache: Throbbing
Region of headache:
Associated symptoms:
Neurological symptoms: blurred vision, no numbness or new weakness in any extremities.
Ocular symptoms:
Nausea/vomiting: Nausea but no vomiting
Fevers/chills: None
Not on blood thinners:
No history of intracranial injury in past or intracranial operative interventions or known aneurysms.
Suspect headache of benign etiology.
Patient is non-toxic given history and examination.
No red flags for headache, hence further work up not indicated and patient appropriate for continued outpatient management.
Specifically:
_Doubt meningitis given no neck stiffness, afebrile, well appearing, no altered mental status.
_Doubt acute traumatic intracranial injury given no hx consistent with severe mechanism, benign nuero exam (as above).
_Doubt acute cerebral vascular accident given benign neuro exam (as above).
No red flags for headache, hence further work up not indicated and patient appropriate for continued outpatient management.
Specifically:
_Doubt meningitis given no neck stiffness, afebrile, well appearing, no altered mental status.
_Doubt acute traumatic intracranial injury given no hx consistent with severe mechanism, benign nuero exam (as above).
_Doubt acute cerebral vascular accident given benign neuro exam (as above).
_Doubt intracranial mass given benign neuro exam, headaches NOT worse in morning.
Not on blood thinners:
No history of intracranial injury in past or intracranial operative interventions or known aneurysms.
*This information is intended for educational purposes only and not intended for use in patient care (which requires a trained credentialed attending physician and individualization of the medical care plan to the specific patient).