Reply to Discussion_Case Study Migraine _Deborah

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What additional questions would you ask to learn more about her headaches?

Additional questions to ask the patient are (Dunphy, Winland-Brown, Porter, & Thomas, 2015):

• Onset, location, character, numbness
• How many headaches does she have in a week or month?
• Does she experience an aura before the onset of pain?
• Is there a family history of headaches?
• Do you experience changes in vision?
• Is there a history of trauma to the head?
• Have you noticed a relationship between the headaches and menstrual cycle?

How do you classify headaches?

According to the International Classification of Headache Disorders (2019), headaches are classified into two categories: Primary and Secondary. Primary headaches includes migraines, tension-type headaches, and trigeminal autonomic cephalalgias. Secondary headaches are those that are attributed to trauma, substance withdrawal, hormones, or infection.

How can you determine if this is an old headache or a new headache/s? Is this a chronic or episodic condition?

Establishing the onset of symptoms will provide insights as to whether or not this is a new headache or an old one. Chronic migraines are classified as headaches 15 or more days/month on at least 8 days/month for more than 3 months (ICHD-3, 2019). It is nearly impossible to distinguish individual headaches for those experiencing episodic migraines due to the frequency.

Can you make a definite diagnosis through an open-ended history followed by focused questions?

The use of open-ended questions will contribute to the differential diagnosis and differentiate between a primary or secondary headache and to rule out other diagnosis. The location and characteristics of the pain along with associated symptoms are important in diagnosing the type of headache. The type of headache will then direct the physical assessment and tests to be ordered. The physical exam should focus on the neurological system.

How can you use the patient history to distinguish between benign headaches and serious ones that require urgent attention?

The patient history will provide insights as to any trauma to the head as well as red flag symptoms such as sudden onset of severe pain, vomiting, and descriptors such as “worse headache ever” (Dunphy et al., 2015).

What diagnostic tests do you want to include to help with your diagnosis?

• CBC and CMP
• Urinalysis
• Thyroid-TSH and T4
• Estradiol and Progesterone levels
• CT
• MRI if indicated based on CT results and symptom presentation

Create a differential diagnosis flow sheet for this patient and include the diagnostics related to the differentials.

References

Dunphy, L., Winland-Brown, J., Porter, B., & Thomas, D. (2015). Primary Care: The art and science of advance practice nursing, (4^th Ed.). Philadelphia, PA: F.A. Davis Company

International Classification of Headache Disorders. (2019). HIS Classification ICHD-3. Retrieved from ichd-3.org.