Latest 2025 October # Week 9 Comprehensive iHuman Case Study: 26 Year-Old Female Patient, Exams of Integrated Case Studies

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Latest 2025 October # Week 9

Comprehensive iHuman Case Study: 26 -

Year-Old Female Patient with More Frequent

Severe Headaches (Class 6512)

Comprehensive iHuman Case Study: 26-

Year-Old Female with Severe Frequent

Headaches

1. Complete History

Chief Complaint (CC)

• Severe, frequent headaches for the past 3 months, occurring 3-4 times per week.

History of Present Illness (HPI)

Sarah Johnson, a 26-year-old female, presents to the primary care clinic complaining of severe headaches for the past 3 months. The headaches began gradually and have progressively increased in frequency and intensity, now occurring 3-4 times per week. The pain is described as unilateral, predominantly right-sided, located around the temple and periorbital region. Each episode lasts 4-6 hours and is characterized as throbbing and pulsating in nature, with a severity of 7-9/10 on the pain scale. The headaches are accompanied by nausea, occasional vomiting, photophobia, and phonophobia, which significantly impair her ability to work and perform daily activities. Aggravating factors include exposure to bright lights, loud noises, stress from work, and sleep deprivation (patient reports sleeping 5-6 hours per night). Partial relief is achieved by resting in a dark, quiet room and taking over-the-counter ibuprofen (4 00 - 600 mg), though relief is incomplete and inconsistent. The patient denies any prodromal symptoms, aura (e.g., visual disturbances), or focal neurological symptoms such as weakness or numbness. There is no history of head trauma, recent infections, or changes in vision unrelated to headache episodes. The patient notes increased stress due to a demanding new job as a graphic designer and irregular meal and sleep schedules. She denies changes in headache pattern with menstruation but reports using oral contraceptives for 2 years.

Past Medical History (PMH)

• Mild Asthma : Diagnosed at age 16, well-controlled with albuterol inhaler as needed (last used 6 months ago).
• No History of : Head trauma, seizures, neurological disorders, hypertension, diabetes, or chronic illnesses.
• Allergies : No known drug, food, or environmental allergies.
• Surgeries : None.

• Medications : Oral contraceptive pills (ethinyl estradiol/levonorgestrel), ibuprofen as needed for headaches.

Social History (SH)

• Smoking : Non-smoker, no history of tobacco use.
• Alcohol : Occasional use (1-2 glasses of wine per week).
• Illicit Drugs : Denies use of recreational drugs.
• Occupation : Graphic designer, reports high stress due to tight project deadlines and long work hours.
• Lifestyle : Sedentary, no regular exercise. Consumes 2-3 cups of coffee daily and has an irregular sleep schedule (5-6 hours/night). Lives alone, single, with a supportive social network.
• Diet : Irregular meals, often skips breakfast due to time constraints.

Family History (FH)

• Mother : Diagnosed with migraines without aura at age 30, well-managed with medication.
• Father : Hypertension, diagnosed at age 50, on treatment.
• Siblings : One younger sister, healthy.
• No History of : Stroke, brain tumors, aneurysms, or other neurological disorders in immediate family.

OB/GYN History

• Menarche : Age 12.
• Menstrual History : Regular cycles, every 28-30 days, lasting 5 days, moderate flow, no dysmenorrhea.
• Gravida/Para : G0P0 (no pregnancies).
• Contraception : Oral contraceptive pills (ethinyl estradiol/levonorgestrel) for 2 years.
• Gynecological History : No history of pelvic inflammatory disease, endometriosis, or ovarian cysts. Last Pap smear 1 year ago, normal. 2. Physical Exam & Vitals

Vitals

• Blood Pressure : 118/76 mmHg (normal).
• Heart Rate : 72 beats/min, regular rhythm.
• Respiratory Rate : 16 breaths/min.

include a family history of migraines, high occupational stress, irregular sleep (5-6 hours/night), excessive caffeine intake (2-3 cups/day), and oral contraceptive use. The patient’s vital signs and physical examination are unremarkable, with no neurological deficits, papilledema, or red flags (e.g., sudden onset, fever, or focal neurological signs) to suggest a secondary headache disorder. The presentation strongly supports a primary headache disorder, specifically migraine without aura, with potential contributions from lifestyle and hormonal factors.

4. Differential & Final Diagnoses

Differential Diagnoses

1. Migraine without Aura : o Likelihood : High. The patient meets IHS criteria (2024): ≥5 attacks, duration 4- 72 hours, unilateral, throbbing, moderate-to-severe intensity, aggravated by routine activity, with nausea, photophobia, and phonophobia. o Supporting Factors : Family history of migraines, triggers (stress, sleep deprivation, caffeine).
2. Tension-Type Headache : o Likelihood : Low. Pain is not bilateral, pressing, or band-like, and associated symptoms (nausea, photophobia) are atypical for tension-type headaches.
3. Cluster Headache : o Likelihood : Very low. No autonomic symptoms (lacrimation, nasal congestion) or shorter duration (15-180 minutes). More common in males.
4. Medication-Overuse Headache : o Likelihood : Moderate. Frequent ibuprofen use could contribute, but headache onset predates potential overuse. Headache diary needed to confirm frequency of analgesic use.
5. Secondary Headache (e.g., Brain Tumor, Subarachnoid Hemorrhage) : o Likelihood : Very low. No red flags (sudden onset, worst headache ever, neurological deficits, papilledema, or systemic symptoms like fever or weight loss).
6. Cervicogenic Headache : o Likelihood : Low. No neck pain, stiffness, or history of cervical trauma.
7. Hormonal Headache : o Likelihood : Moderate. Oral contraceptive use may exacerbate migraines, but headaches are not exclusively menstrual-related.

Final Diagnosis

• Migraine without Aura (IHS Classification, 2024).

• Possible Contributor : Medication overuse (pending headache diary review) and hormonal influence from oral contraceptives. 5. Investigations & Results

Investigations Ordered

Per 2024 American Headache Society (AHS) guidelines, diagnostic testing is not required for typical migraine without red flags. However, the following were ordered to rule out secondary causes and establish a baseline:

• Neurological Examination : To confirm absence of focal deficits or signs of increased intracranial pressure.
• Fundoscopic Exam : To exclude papilledema.
• Complete Blood Count (CBC) : To rule out anemia or infection as contributing factors.
• Comprehensive Metabolic Panel (CMP) : To assess electrolytes, liver, and kidney function.
• Thyroid Function Tests (TSH, Free T4) : To rule out thyroid dysfunction as a headache trigger.
• Erythrocyte Sedimentation Rate (ESR) and C-Reactive Protein (CRP) : To exclude inflammatory conditions (e.g., temporal arteritis, though unlikely given age).
• Headache Diary : To track headache frequency, duration, triggers, and medication use over 4 weeks.
• Brain Imaging (MRI/CT) : Not indicated unless red flags emerge (e.g., new neurological deficits, atypical headache pattern).
• EEG : Not indicated unless seizures are suspected (no history of seizures).

Hypothetical Results

• Neurological Exam : Normal, no focal deficits.
• Fundoscopic Exam : No papilledema or retinal abnormalities.
• CBC : Hemoglobin 13.2 g/dL (normal), white blood cell count 6.5 x 10³/μL (normal), platelets 250 x 10³/μL (normal).
• CMP : Sodium 138 mmol/L, potassium 4.0 mmol/L, glucose 90 mg/dL, creatinine 0. mg/dL (all normal).
• TSH : 2.3 mIU/L (normal range 0.4-4.5 mIU/L).
• ESR : 10 mm/hr (normal for age and sex).
• CRP : 0.5 mg/L (normal).
• Headache Diary : Confirms 3-4 headaches/week, triggered by stress, sleep deprivation, and caffeine; ibuprofen used 2-3 times/week.

• Occupation: Graphic designer, high stress due to work deadlines.
• Lifestyle: Sedentary, 2-3 cups coffee/day, irregular sleep (5-6 hours/night), irregular meals.
• Single, lives alone, supportive social network. Family History :
• Mother: Migraines without aura, diagnosed at age 30.
• Father: Hypertension.
• No family history of stroke, brain tumors, or aneurysms. OB/GYN History :
• Menarche: Age 12.
• Cycles: Regular, 28-30 days, 5 days duration, moderate flow.
• G0P0, on oral contraceptives for 2 years.
• Last Pap smear: 1 year ago, normal. Review of Systems :
• Neurological : Headaches as described, no weakness, numbness, or vision changes.
• General : Fatigue due to poor sleep, no weight loss or fever.
• ENT : No sinus pain, congestion, or hearing changes.
• Cardiovascular : No chest pain or palpitations.
• Respiratory : No shortness of breath or wheezing.
• GI : Nausea/vomiting with headaches, no abdominal pain.
• Musculoskeletal : No neck stiffness or joint pain.
• Psychiatric : Increased stress, no depression or anxiety history. O: Objective Vitals :
• Blood Pressure: 118/76 mmHg
• Heart Rate: 72 beats/min, regular
• Respiratory Rate: 16 breaths/min
• Oxygen Saturation: 98% on room air
• Temperature: 98.4°F (36.9°C)
• Weight: 60 kg
• Height: 5’5” (165 cm)
• BMI: 22 kg/m² (normal)

Physical Exam :

• General : Well-groomed, alert, no acute distress, appears fatigued.
• HEENT : o Head: Normocephalic, atraumatic, no scalp tenderness. o Eyes: PERRLA, extraocular movements intact, fundoscopic exam normal (no papilledema). o Ears: Tympanic membranes clear. o Nose/Sinuses: No tenderness or congestion. o Throat: Oropharynx clear.
• Cardiovascular : S1, S2 normal, no murmurs, rubs, or gallops. Peripheral pulses 2+.
• Respiratory : Lungs clear bilaterally, no wheezes or crackles.
• Abdomen : Soft, non-tender, no organomegaly, normal bowel sounds.
• Extremities : No edema, clubbing, or cyanosis.
• Neurological : o Mental Status: Alert, oriented x4. o Cranial Nerves: II-XII intact. o Motor: 5/5 strength bilaterally. o Sensory: Intact to light touch, pinprick, vibration. o Coordination: Normal finger-to-nose, heel-to-shin. o Gait: Steady, no ataxia. o Reflexes: 2+ symmetric (biceps, triceps, patellar, Achilles).
• Skin : No rashes or lesions.
• Musculoskeletal : Normal cervical spine range of motion, no neck stiffness. Diagnostic Tests :
• CBC : Hemoglobin 13.2 g/dL, WBC 6.5 x 10³/μL, platelets 250 x 10³/μL (normal).
• CMP : Sodium 138 mmol/L, potassium 4.0 mmol/L, glucose 90 mg/dL, creatinine 0. mg/dL (normal).
• TSH : 2.3 mIU/L (normal).
• ESR : 10 mm/hr (normal).
• CRP : 0.5 mg/L (normal).
• Fundoscopic Exam : No papilledema.
• Headache Diary : Initiated to track frequency, triggers, and medication use. A: Assessment Primary Diagnosis :

o Diet : Regular meals, hydrate (2-3 L/day), avoid dietary triggers. o Exercise : 150 min/week moderate activity (e.g., brisk walking).

4. Hormonal Evaluation : o Assess oral contraceptive contribution to migraines. Discuss progestin-only or non-hormonal options if correlated with headache pattern.
5. Diagnostic Monitoring : o Headache Diary : Track frequency, duration, triggers, and medication use for 4 weeks. o No imaging or EEG indicated unless red flags (e.g., focal deficits, atypical features) emerge.
6. Patient Education : o Provide handout on migraine management, medication use, lifestyle changes, and warning signs (sudden severe headache, neurological symptoms). o Resources: American Migraine Foundation (www.americanmigrainefoundation.org), National Headache Foundation (www.headaches.org).
7. Follow-Up : o Schedule appointment in 4 weeks to review headache diary, assess treatment response, and adjust medications. o Refer to neurology if no improvement after 3 months or atypical features develop. o Consider behavioral health referral for stress management if needed.
8. Documentation : o Update medical record with diagnosis, plan, and patient education provided. 6. Management

General Management

• Setting : Outpatient primary care management.
• Monitoring : Initiate headache diary to track symptoms and treatment response.
• Education : Counsel on migraine triggers, lifestyle modifications, and medication adherence.
• Multidisciplinary Approach : Consider referral to a headache specialist or neurologist if no improvement after 3 months.

Emergency Management

• Not Indicated : No evidence of status migrainosus (headache >72 hours) or red flags requiring urgent evaluation (e.g., thunderclap headache, neurological deficits).

Treatment Plan

Based on 2024 AHS and IHS guidelines for migraine management:

• Acute Treatment : o Sumatriptan : 50 mg oral at headache onset, may repeat after 2 hours if partial response (max 200 mg/day). Contraindicated in uncontrolled hypertension or cardiovascular disease. o Ibuprofen : 400-800 mg oral as needed for mild-to-moderate attacks (max 3200 mg/day). Limit to <10 days/month to avoid medication-overuse headache. o Metoclopramide : 10 mg oral as needed for nausea, to enhance triptan absorption and treat associated symptoms.
• Preventive Treatment (indicated due to >4 headache days/month, per AHS guidelines): o Propranolol : Start 20 mg daily, titrate to 80-160 mg daily in divided doses over 4 - 6 weeks. Monitor for bradycardia or hypotension. o Alternative Options (if propranolol contraindicated or ineffective): ▪ Topiramate : Start 25 mg daily, titrate to 100 mg daily over 4 weeks. Monitor for cognitive side effects and paresthesia. ▪ Amitriptyline : 10-50 mg nightly if coexisting sleep disturbance or anxiety.
• Lifestyle Modifications : o Sleep Hygiene : Aim for 7-8 hours of consistent sleep nightly. Avoid screen time 1 hour before bed. o Caffeine Reduction : Limit to 1 cup of coffee/day (100-200 mg caffeine) to minimize rebound headaches. o Stress Management : Engage in mindfulness, yoga, or cognitive behavioral therapy (CBT). o Diet : Regular meals, adequate hydration (2-3 L/day), avoid known dietary triggers (e.g., processed foods, alcohol). o Exercise : 150 minutes/week of moderate aerobic activity (e.g., brisk walking) to reduce stress and improve overall health.
• Hormonal Evaluation : Discuss potential role of oral contraceptives in exacerbating migraines. Consider switching to progestin-only contraception or non-hormonal methods if headaches correlate with hormonal cycles.

Doctor Plan

• Follow-Up : Schedule follow-up in 4 weeks to review headache diary, assess treatment response, and adjust medications.
• Referral : Refer to neurology if headaches persist despite optimized therapy or if atypical features develop.
• Additional Considerations : Offer referral to a behavioral health specialist for stress management or CBT if stress remains a significant trigger.
• Monitoring : Reassess ibuprofen use to prevent medication-overuse headache (limit to <10 days/month).

• Sumatriptan (50 mg) : Take at the first sign of a migraine. You may take another dose after 2 hours if needed (max 200 mg/day). Do not use if you have heart disease or uncontrolled blood pressure. Side effects: Tingling, warmth, or chest tightness.
• Ibuprofen (400-800 mg) : For mild headaches, take as needed (max 3200 mg/day). Use sparingly (<10 days/month) to avoid rebound headaches.
• Metoclopramide (10 mg) : Take for nausea during a migraine. Side effects: Drowsiness or restlessness.
• Propranolol (20 mg daily, increasing to 80-160 mg) : Take daily to prevent migraines. Report dizziness, fatigue, or slow heart rate. Lifestyle Changes :
• Sleep : Aim for 7-8 hours of sleep nightly. Keep a consistent bedtime and avoid screens before bed.
• Caffeine : Limit to 1 cup of coffee/day (100-200 mg) to prevent triggering headaches.
• Stress : Practice relaxation techniques like deep breathing, meditation, or yoga. Consider professional counseling for work-related stress.
• Diet : Eat regular, balanced meals (include breakfast). Stay hydrated (2-3 L water/day). Avoid processed foods or alcohol if they trigger headaches.
• Exercise : Engage in 30 minutes of moderate activity (e.g., walking) 5 days/week.
• Headache Diary : Record each headache’s timing, duration, triggers, and medication use to help us tailor your treatment. Warning Signs :
• Seek Immediate Care (Call 911) : If you experience a sudden, severe headache (“worst ever”), vision loss, weakness, numbness, confusion, or speech difficulty.
• Contact Your Doctor : If headaches increase in frequency, change in character, or if new symptoms (e.g., vision changes) appear. Follow-Up : Schedule a visit in 4 weeks to review your headache diary and adjust treatment. Contact us sooner if needed. Resources :
• American Migraine Foundation : www.americanmigrainefoundation.org
• National Headache Foundation : www.headaches.org
• Local Support : Ask about headache support groups or stress management programs. 9. Reflection Report

Reflection on Patient Case Management

Managing Sarah’s case of migraine without aura provided a robust opportunity to apply evidence-based guidelines and clinical reasoning in a primary care setting. The patient’s presentation aligned closely with IHS diagnostic criteria (2024), allowing confident diagnosis without unnecessary imaging, which reinforced the importance of a thorough history and physical exam in ruling out secondary causes. The decision to initiate both acute (sumatriptan) and preventive (propranolol) therapies was driven by the high frequency of attacks (> days/month) and their impact on her quality of life, consistent with AHS recommendations. Challenges included addressing the patient’s lifestyle factors, particularly her high stress and irregular sleep, which required empathetic and practical counseling. I found the use of a headache diary particularly valuable, as it empowered the patient to identify triggers and track progress, aligning with patient-centered care principles. However, I recognized the need to improve my skills in motivational interviewing to enhance adherence to lifestyle changes, as Sarah expressed difficulty balancing work demands with self-care. This case highlighted the interplay of hormonal, environmental, and genetic factors in migraines. Exploring the potential role of oral contraceptives was a key learning point, as it prompted consideration of alternative contraception options. Moving forward, I plan to deepen my knowledge of non-pharmacological interventions, such as biofeedback and CBT, and collaborate with multidisciplinary teams (e.g., neurology, behavioral health) to optimize outcomes. This experience underscored the importance of longitudinal care in chronic conditions like migraines, emphasizing follow-up and patient empowerment.

10. PowerPoint Presentation Outline

Slide 1: Title Slide

• Title : Comprehensive Management of Migraine without Aura: A Case Study
• Presenter : [Your Name]
• Institution : [Your Institution]
• Date : July 6, 2025

Slide 2: Case Introduction

• Patient : Sarah Johnson, 26-year-old female.
• Chief Complaint : Severe, frequent headaches for 3 months.
• Objective : Diagnose, manage, and educate patient on migraine without aura.

Slide 3: Complete History

• Warning Signs: When to seek care.
• Resources: American Migraine Foundation, headache support groups.

Slide 10: Reflection

• Learnings : Importance of history, trigger identification, patient empowerment.
• Challenges : Addressing lifestyle barriers, hormonal factors.
• Future Goals : Improve motivational interviewing, explore CBT/biofeedback.

Slide 11: References

• International Headache Society. (2024). The International Classification of Headache Disorders, 4th Edition.
• American Headache Society. (2024). Guidelines for the Management of Migraine.
• Silberstein, S. D., et al. (2024). “Preventive Treatment of Migraine.” Neurology.
• Sacco, S., et al. (2024). “Hormonal Influences on Migraine.” Headache Journal.