,Patient: 26-Year-Old Female
Setting: Outpatient Clinic
Year: 2025
Reason for Encounter: More frequent and severe headaches
Chief Complaint
The patient presents with frequent, severe headaches that have increased in frequency and intensity over the
past few months.
Patient Details
• Age: 26 years
• Sex: Female
• Height: 66 in
• Weight: 122 lb
• BMI: 19.7
• Vital Signs:
o Temperature: 36.9°C (98.5°F)
o Pulse: 80 bpm, regular
o Respiratory Rate: 18
o Blood Pressure: 122/78 mmHg
o SpO₂: 95%
• General Appearance: Awake, alert, oriented ×4, normal strength
History of Present Illness (HPI)
• Headaches have increased in frequency, now occurring several times per week.
• Location: Primarily temporal; sometimes behind the eye.
• Character: Throbbing, moderate to severe intensity.
• Associated Symptoms: Photophobia, nausea, occasional vomiting.
• Exacerbating Factors: Bright lights, stress, sleep deprivation.
• Relieving Factors: Rest in dark environment, limited relief with over-the-counter ibuprofen.
• No recent trauma, fever, vision changes, or neurological deficits.
Past Medical & Surgical History
• No chronic conditions reported
• No prior surgeries
Medications
• Ibuprofen 400–600 mg PRN headaches
, • Oral contraceptive pill
Allergies
• No known drug allergies
Family & Social History
• Family: Mother has migraines; father has hypertension
• Social: Works full-time in high-stress office job, occasional alcohol, no tobacco or illicit drug use,
irregular sleep patterns
Review of Systems (ROS)
• Neurological: Headaches, photophobia, nausea; negative for dizziness, syncope, seizures
• HEENT: Light sensitivity; negative for vision loss or sinus pain
• Constitutional: Negative for fever, fatigue, or weight loss
Physical Examination
• General: Alert, oriented ×3, mildly uncomfortable
• Neurological: Cranial nerves II–XII intact; strength 5/5; sensation intact; normal gait
• HEENT: Pupils equal, reactive to light; fundoscopic exam normal; no sinus tenderness
• Vitals: BP 122/78 mmHg, HR 80 bpm, RR 18, Temp 98.5°F, SpO₂ 95%
Assessment (Differential Diagnosis)
1. Migraine without Aura (Primary) – Most consistent with history and family history
2. Tension-Type Headache – Less likely given severity and associated nausea
3. Medication Overuse Headache – Possible contributor
4. Secondary Headache – Unlikely; no red flag signs
Plan of Care
Diagnostics:
• Maintain headache diary
• Neuroimaging not indicated unless red flags develop
Pharmacologic Management:
• Initiate sumatriptan PRN for acute migraine
Setting: Outpatient Clinic
Year: 2025
Reason for Encounter: More frequent and severe headaches
Chief Complaint
The patient presents with frequent, severe headaches that have increased in frequency and intensity over the
past few months.
Patient Details
• Age: 26 years
• Sex: Female
• Height: 66 in
• Weight: 122 lb
• BMI: 19.7
• Vital Signs:
o Temperature: 36.9°C (98.5°F)
o Pulse: 80 bpm, regular
o Respiratory Rate: 18
o Blood Pressure: 122/78 mmHg
o SpO₂: 95%
• General Appearance: Awake, alert, oriented ×4, normal strength
History of Present Illness (HPI)
• Headaches have increased in frequency, now occurring several times per week.
• Location: Primarily temporal; sometimes behind the eye.
• Character: Throbbing, moderate to severe intensity.
• Associated Symptoms: Photophobia, nausea, occasional vomiting.
• Exacerbating Factors: Bright lights, stress, sleep deprivation.
• Relieving Factors: Rest in dark environment, limited relief with over-the-counter ibuprofen.
• No recent trauma, fever, vision changes, or neurological deficits.
Past Medical & Surgical History
• No chronic conditions reported
• No prior surgeries
Medications
• Ibuprofen 400–600 mg PRN headaches
, • Oral contraceptive pill
Allergies
• No known drug allergies
Family & Social History
• Family: Mother has migraines; father has hypertension
• Social: Works full-time in high-stress office job, occasional alcohol, no tobacco or illicit drug use,
irregular sleep patterns
Review of Systems (ROS)
• Neurological: Headaches, photophobia, nausea; negative for dizziness, syncope, seizures
• HEENT: Light sensitivity; negative for vision loss or sinus pain
• Constitutional: Negative for fever, fatigue, or weight loss
Physical Examination
• General: Alert, oriented ×3, mildly uncomfortable
• Neurological: Cranial nerves II–XII intact; strength 5/5; sensation intact; normal gait
• HEENT: Pupils equal, reactive to light; fundoscopic exam normal; no sinus tenderness
• Vitals: BP 122/78 mmHg, HR 80 bpm, RR 18, Temp 98.5°F, SpO₂ 95%
Assessment (Differential Diagnosis)
1. Migraine without Aura (Primary) – Most consistent with history and family history
2. Tension-Type Headache – Less likely given severity and associated nausea
3. Medication Overuse Headache – Possible contributor
4. Secondary Headache – Unlikely; no red flag signs
Plan of Care
Diagnostics:
• Maintain headache diary
• Neuroimaging not indicated unless red flags develop
Pharmacologic Management:
• Initiate sumatriptan PRN for acute migraine
