37 year old male – notes headaches that have been intermittent have now become more regular over last 3 months, especially in last 3 weeks. His headaches have usually been on the right side and are disabling. He becomes very sensitive to sound and nauseated. He has used two sick days in the last month due to the severity of a headache. First episode, the headache last approximately 18 hours and persisted even though he slept in a dark room and took pepto-bismol and Tylenol. Second episode the headache lasted longer – nearly 24 hours and he went to urgent care where they gave him “a shot” and he felt better. He has had multiple less severe headaches that don’t interfere with his activity as much, though he is still sensitive to light/sounds/smells and they will last all afternoon/evening and be gone the next morning. These occur about every 2 days. His headaches have occurred equally on weekdays/weekends. He is concerned about the headaches increasing as he works on a factory floor as a supervisor and the environment is intolerable when he has a headache.
Headache history: He does note that he knows when a headache is coming. He’s had flashes of light and “just feels bad” before the headache comes on. They are unilateral and he can “hear his pulse beat in his head”. Medications (Tylenol, motrin) are not typically very effective. He Notes that his Mom has headaches as well.
Social History – he is not a smoker, but almost all the personnel he supervises are and there is significant secondhand smoke. He rates his job as “very stressful” and thinks about it most nights while he is trying to go to sleep, and he is especially worried about the days he’s had to take off due to headaches. He was previously treated for depression and neck pain with Cymbalta after a neck injury at work, but went off of it for insurance reasons.
Exam: HR 76 BP 119/70
No sinus tenderness, Normal tymp membranes. No visual deficits, no blurring of retinal discs. CN2-12 Grossly intact.
No motor weakness, though there is increased tone at the right trapezius with some minimal tenderness. Gait and coordination are normal. Speech production and comprehension are normal.
What issues in the daily environment contribute?
What tests do you want to do in clinic today?
What prescriptions could help with the headache?