18 year old girl with continuous headache throughout the day since 6 months

18 YEAR OLD GIRL WITH CONTINUOUS HEADACHE THROUGHOUT THE DAY SINCE THE LAST 6 MONTHS

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A 18 year old girl studying in intermediate 2 nd year ( BiPC ) residing in Nampally mandal, Nalgonda district presented to the OPD with chief complaint of headache since 1 year .

History of presenting illness : The patient was apparently asymptomatic 5 years back, then she developed intermittent episodes of headache that did not have any aggravating factors and releived with medications .

One year back ( 09-08-2021 ) , the patient went to a hospital in Nalgonda for her headache, where they did an eye checkup ( she did not have any sight ) and adviced her to wear non sight glasses for her headache ( but the patient does not find any improvement in her headache ) .

Now, since 6 months she is having severe continuous bilateral throbbing type of headache more in the temporal region that aggravates by evenings and is not associated with nausea, vomitings . There is no diplopia, vision or auditory problems .

Around 1 month ago she visited another hospital for her headache, where they had prescribed her Sertraline ( 25 mg ) and Escetalopram ( 5 mg ) for 1 month, but she took the tablets only for 8 days as her headache had decreased .

But as she again started having continuous headache, she visited KIMS Narketpally twice , was given medications :

19/11/22 - naxdom, calcium, multivitamin, pantop

29/11/22 - ibuprofen, amitryptilline 

AGGRAVATING FACTORS FOR HER HEADACHE

- when she consumes cold food 

- consumes any type of fruits in the mornings

- drinks normal room temperature water ( she avoids or tries to drink less water especially in the mornings after waking up )

- eating curd at nights for dinner

- loud noises and listening to songs

- during exams when she is stressed

RELEIVING FACTORS :  headache is temporarily releived when she drinks tea and sleeps for sometime .

Personal history : The patient wakes up at around 6 - 7 am in the morning, freshens up and has her breakfast at around 8 am which is usually rice with any curry . Then she goes to her college in Nampally by walking and attends college from 9 am to 4 pm . She takes lunch box from home and eats in college at around 1pm . After she returns home at 4 pm, she does some house chores like dishwashing ( as her mom works as a nurse ) and watches tv or studies for sometime upto 5:30 pm . She then takes rest from 6 pm to 7 pm . She has her dinner at 8 pm and sleeps by 9 pm .

Diet - mixed ( consumes chicken once a week )

Appetite - normal

Sleep - disrturbed ( wakes up in the middle of the night due to severe headache )

Bowel and bladder movements - regular

Past history : The patient is not a known case of hypertension, diabetes, asthma, epilepsy .

Family history : Her mother also gets headache in the temporal region on consuming cold foods that relieves in 3 days with or without tablets .

General Examination : The patient is conscious, coherent, cooperative, well built and nourished .

Pallor, icterus, cyanosis, clubbing, generalised lymphadenopathy and pedal edema are absent.

VITALS : 

Temperature - afebrile

HR - 73 bpm

BP - 120/80 mmHg

RR - 18 cpm

Systemic Examination : 

CNS : The patient is well oriented to time, place, person.

Higher mental functions are intact.

Cranial nerve examination :‐

All cranial nerves are intact and functioning. 

Motor System Examination :‐

• Normal bulk in upper and lower limbs

• Normal tone in upper and lower limbs

• Normal power in upper and lower limbs

• Gait is normal .

. Reflexes are normal .

Sensory System Examination :‐

Normal sensations are felt in all the dermatomes.

No cerebellar signs .

No meningeal signs.

CVS : 

On palpation ‐

• Apex beat was felt in the left 5th intercostal space medial to the mid clavicular line. 

• JVP was normal 

• No parasternal heave

On auscultation ‐ S1, S2 heard , no murmurs 

RS :

On inspection ‐

• Chest is bilaterally symmetrical 

• Expansion of chest: Equal on both sides

• Position of trachea: Central

• No visible scars, sinuses, pulsations

On palpation : 

• Expansion of chest was equal on both sides. 

• Position of trachea: Central

• Tactile Vocal Fremitus: resonant note was felt.

On percussion: all lung areas were resonant 

On auscultation : 

• Bilateral air entry was present, normal vesicular breath sounds were heard. 

• Vocal resonance: resonant in all areas

P/A : soft, non tender, no organomegaly, no distension, bowel sounds heard.

Investigations :

Hemogram 

CUE

Serum urea

Serum creatinine

ESR

Electrolyte levels

ECG

Differential diagnosis : 

Chronic migraine

Tension headaches

Cluster headaches

Provisional Diagnosis : Headache in the temporal region which may be due to stress? or tension? or any arteritis in the brain? under evaluation

Treatment :

1) Tab. Naproxen 250 mg PO TID for 5 days

2) Multivitamin tablet PO OD for 15 days