Headaches

Scenario: Gina is a healthy 32-year-old lawyer who presents to the clinic with recent onset of intermittent headaches. She recently started at a new law firm and has been under a lot of stress. Her headaches can last 4 hours or more and they are a moderate to severe pulsation quality. She has had to leave work on at least 5 occasions over the last two months. During a headache, she has photophobia and nausea. Lying down in a dark room with a cold compress helps as she eventually falls asleep. Ibuprofen has been mildly effective, but she can’t tolerate it when she is nauseated. She is worried that she is missing too much work at her new job.

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1. What should the initial history and physical examination include?
2. Would you order diagnostic tests on Gina? Provide your rationale for why or why not.
3. What are the differential diagnoses for this patient?
4. What is the most likely diagnosis for this patient? Explain your answer.
5. What are the first line initial treatment recommendations for management of this disorder? Provide pharmacological (with full prescription details) and nonpharmacological treatment options.
6. What patient education should you discuss with Gina?

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