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INTRODUCTION

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CASE LEARNING OBJECTIVES

  • Differentiate among types of headaches (HAs) based on symptoms and signs

  • List underlying causes and precipitating factors of different types of HA disorders

  • Recommend appropriate nonpharmacologic measures for HA treatment and prevention

  • On the basis of patient-specific data, determine when pharmacologic therapy is indicated for HA

  • Propose individualized pharmacologic treatment regimens for the acute and chronic management of HA syndromes

  • Construct therapeutic and adverse effect monitoring plans for patients with HA

  • Discuss pertinent patient education points for patients with HA disorders

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PATIENT PRESENTATION

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Chief Complaint

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"My headaches just won't go away no matter how many pills I take."

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History of Present Illness

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XA is a 54-year-old man who is evaluated by the outpatient neurology service of an academic medical center due to chronic daily HA, which has recently grown more severe. He reports that his HAs are bitemporal and that the pain radiates into his neck and upper back, but that they are not associated with stiffness or weakness: "It feels like a heavy weight on my head and shoulders." The pain is nonpulsatile, grows steadily over hours until it is 8/10 in intensity; and it lasts most of the day, if left untreated. "Almost anything" can bring on a HA, but they are more frequent and more intense when he is under significant "stress." He reports that worry over recent marital problems makes it difficult for him to fall asleep. Bright lights can make the pain worse, but he has not experienced nausea or any neurologic deficits prior to or during an attack. The pain makes it difficult to concentrate, though he rarely misses business or family obligations. He has experienced HA since his teenage years, but they had previously been easy to treat with the use of OTC analgesics. Over the past several years, his HAs have become more difficult to control. His primary care physician (PCP) provided him prescription-strength NSAIDs for PRN use without much relief: "I take them every day; they don't seem to do much good." His other health issues remain stable, although he is scheduled for a prostate biopsy to further evaluate an elevated screening PSA test.

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Past Medical History

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Dyslipidemia

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Gastritis, s/p treatment for Helicobacter pylori

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Generalized anxiety disorder (GAD), diagnosed at age 44 years, stable on medication therapy for 2 years

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HTN

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Seasonal allergic rhinitis

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Family History

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Mother aged 79 years has diabetes and suffers from migraine HA. His father had an open prostatectomy for cancer at age 64 years, and died of a stroke at 84 years. His daughter, age 23 years, is treated for recurrent depression.

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Social History

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He was divorced from his wife of 25 years 6 ...

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