The Correct Answer is A!

A 42-year-old woman presents to clinic complaining of a headache that occurs about 2-3 times per week, each time lasting about 2-3 hours. She describes the headache as a tightening pain in the back of her head on both sides. She is mildly sensitive to light, but noise does not bother her. She denies nausea or vomiting. She also denies any visual symptoms such as double vision or vision loss. S

he is still able to function, and exercise does not aggravate the headache. She has had these headaches since her 20s and notes that they are worse with stress and lack of sleep. She takes ibuprofen usually with relief within a half hour. On examination, her temperature is 98.7F, pulse 79/min, blood pressure 129/72 mm Hg. Her neurologic and fundoscopic exams are unremarkable.

Which of the following is the most appropriate next step in the management of this patient?

A. Tension headache
B. Migraine without aura
C. Cluster headache
D. Idiopathic intracranial hypertension

Rationale:

The patient’s presentation is most consistent with a tension-type headache, characterized by bilateral mild to moderate pain with no other significant associated symptoms. Migraines are distinguished from the tension type headache primarily by location (usually unilateral) and more prominent associated symptoms such as nausea, vomiting, and photophobia; also activity usually worsens migraine headaches.

Cluster headaches are distinguished from other headaches by their short duration and association with autonomic symptoms such as conjunctival injection or lacrimation, nasal congestion or rhinorrhea, eyelid edema, facial sweating, and miosis and ptosis. Idiopathic intracranial hypertension usually presents as a daily headache, worse with coughing, sneezing, or lying down. This diagnosis is unlikely here given the lack of vision symptoms and normal funduscopic exam.

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