Posted: September 5th, 2024

Case Study: Migraine Headaches in a 19-Year-Old Female

Case Study: Migraine Headaches in a 19-Year-Old Female

Migraine headaches are a common neurological condition that can significantly impact the quality of life. This case study examines a 19-year-old female presenting with frequent headaches, exploring the clinical presentation, assessment, and management strategies. The aim is to provide a comprehensive understanding of migraine diagnosis and treatment, supported by current evidence.

Subjective Data
Chief Complaint
The patient reports, “I have frequent headaches that have become more debilitating recently.”

History of Present Illness
The patient, a 19-year-old female, has experienced headaches since her teenage years. Recently, these episodes have increased in severity, occurring once or twice a month and lasting up to two days. The pain typically begins in the right temple or behind the right eye, spreading to the entire scalp. She describes the pain as sharp and throbbing, worsening over time, and accompanied by severe nausea. Loud noises and movement exacerbate the pain, while sleeping in a dark, quiet room provides relief. Over-the-counter medications like naproxen and acetaminophen have been ineffective.

Past Medical History
The patient has no significant past illnesses, traumas, or surgeries. Her mother has a history of migraines.

Allergies
The patient reports seasonal allergies and allergies to pet dander but no drug allergies.

Medications
The patient occasionally uses naproxen and acetaminophen for headache relief.

Social History
The patient is a college freshman, sexually active, and uses condoms. She denies alcohol, illicit drug, and tobacco use. She reports no significant stressors beyond typical academic pressures.

Family History
The patient’s mother suffers from migraines. No other significant family medical history is reported.

Health Promotion and Maintenance
The patient is up to date on immunizations and health maintenance for her age. She engages in regular physical activity and follows a balanced diet.

Review of Systems
Constitutional: Denies fever, chills, night sweats.
Head: Reports headaches as described.
Eyes: Denies visual changes other than photophobia.
Ears, Nose, Mouth, Throat: No significant findings.
Neck: Denies stiffness.
Cardiovascular/Peripheral Vascular: Denies chest pain, palpitations.
Respiratory: Denies shortness of breath, cough.
Gastrointestinal: Reports nausea with headaches, denies vomiting.
Neurological: Denies numbness, tingling, weakness, mood changes.
Objective Data
Vitals
Temperature: 98.5°F
Blood Pressure: 112/70 mmHg
Heart Rate: 62 bpm
Respiratory Rate: 17 breaths/min
SpO2: 99% on room air
Height: 68 inches
Weight: 151 lbs
BMI: 23.0
Physical Exam
General Appearance: Alert, oriented, appears stated age.
Head: Normocephalic, no tenderness over sinuses.
Eyes: PERRL, normal visual acuity (20/20).
ENT, Mouth: TM gray with adequate cone of light bilaterally, mucous membranes pink and dry.
Neck: No palpable masses, adenopathy, or thyroid enlargement.
Cardiovascular: Regular heart rate and rhythm, no murmurs.
Respiratory: Lungs clear bilaterally.
Gastrointestinal: Soft, non-tender, non-distended abdomen with normoactive bowel sounds.
Neurological: Normal muscle tone and strength, reflexes 2+ bilaterally, negative Babinski, steady gait.
Assessment and Diagnosis
Diagnosis
Migraine without Aura (ICD-10: G43.0)
Tension-Type Headache (ICD-10: G44.209)
Allergic Rhinitis (ICD-10: J30.9)
Visit Codes
CPT Billing Codes: 99213 (Established Patient Office Visit)
Diagnostics
POC Testing: None required at this time.
Tests Reviewed: None indicated.
Plan
Actions
Diagnosis: Migraine without Aura

Diagnostics Order: None at this time.
Therapeutic: Prescribe sumatriptan 50 mg, PO, at onset of headache, may repeat once after 2 hours if needed, #9, no refills.
Education: Educate on migraine triggers and lifestyle modifications, including regular sleep patterns and stress management techniques.
Consultation/Collaboration: Consider referral to a neurologist if symptoms persist or worsen.
Diagnosis: Tension-Type Headache

Diagnostics Order: None at this time.
Therapeutic: Recommend non-pharmacological interventions such as relaxation techniques and physical therapy.
Education: Discuss the importance of posture and ergonomics in preventing tension headaches.
Consultation/Collaboration: None required at this time.
Diagnosis: Allergic Rhinitis

Diagnostics Order: None at this time.
Therapeutic: Continue current allergy management strategies.
Education: Reinforce avoidance of known allergens and use of antihistamines as needed.
Consultation/Collaboration: None required at this time.
Preventive
Guidance: Encourage regular exercise, balanced diet, and adequate hydration.
Follow-Up: Schedule follow-up in 4-6 weeks to assess treatment efficacy and adjust management plan as needed.

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NU610 Unit 1 Case Study

A 19-year-old female presents with a complaint of headaches frequently. She reports that she has had them since she was a teenager, but they have become more debilitating recently. The episodes occur once or twice a month and last for up to 2 days. The pain begins in the right temple or the back of the right eye and spreads to the entire scalp over a few hours. She describes the pain as a sharp, throbbing sensation that gradually worsens and is associated with sever nausea. Several factors aggravate the pain including loud noises and movement. She has taken several over the counter medication like naproxen and acetaminophen for the pain but the only thing that makes it better is going to sleep in a dark quiet room. Reports no drug allergies but has seasonal and allergies to pet dander. A thorough history reveals her mother suffers from migraines. Last menses 4 weeks ago, is sexually active uses condoms. Currently a freshman in college. Denies alcohol, illicit drug and tobacco use. Last health visit was over the Summer, up to date on health maintenance for her age. She denies fever, chills, night sweats or neck stiffness. She denies visual changes other than photophobia. She denies chest pain, palpitations, shortness of breath or cough. She denies abdominal pain, has some nausea with the headaches but no vomiting. Denies numbness, tingling, weakness or changes in mood. Vital signs: temperature 98.5, BP 112/70, HR 62, RR 17, 99% RA, Ht. 68 inches, Wt. 151 lbs. Alert and oriented to self, place, time and situation. Appears stated age with skin warm and dry. Normocephalic, PERRL, TM gray with adequate conf of light bilaterally, no tenderness over sinuses. Mucous membranes pink and dry. No palpable masses, adenopathy or thyroid enlargement. Regular heart rate and rhythm without murmurs. No edema. Lungs clear bilaterally, no use of accessory muscles. Soft, non-tender, non-distended abdomen with normoactive bowel sounds. Normal visual acuity using Snellen chart 20/20, face symmetrical with symmetrical smile and puffing out cheeks. Weber and Rinne test performed with normal bone and air conduction. Palate and uvula at rest are free of fasciculations and symmetry noted at test and when pt. says “ah.” Positive gag reflex. Shrug shoulders spontaneously and against resistance, hypoglossal nerve intact. Muscle tone inspected, palpated without atrophy and strength 5/5. Bicep, patellar and Achilles reflexes 2+ bilaterally with negative Babinski. Able to distinguish light and deep touch. Able to complete heel to shin, gait steady.

SOAP Note:
S: SUBJECTIVE DATA
CC: What are they being seen for? This is the reason that the patient sought care, stated in their own words/words of their caregiver, or paraphrased.

HPI: Use the “OLDCART” approach for collecting data and documenting findings. [O=onset, L=location, D=duration, C=characteristics, A=associated/aggravating factors, R=relieving factors, T=treatment, S=summary]

PMH: This should include past illness/diagnosis, conditions, traumas, hospitalizations, and surgical history. Include dates if possible.

ALLERGIES State the offending medication/food and the reactions.
MEDICATIONS Names, dosages, and routes of administration along with indication of use.

SH Related to the problem, educational level/literacy, smoking, alcohol, drugs, HIV risk, sexually active, caffeine, work and other stressors. Cultural and spiritual beliefs that impact health and illness. Financial resources.

FH Use terms like maternal, paternal, and the diseases along with the ages they were deceased or diagnosed if known.

HEALTH PROMOTION & MAINTENANCE Required for all SOAP notes: Immunizations, exercise, diet, etc. Remember to use the United States Clinical Preventative Services Task Force (USPSTF) for age-appropriate indicators. This should reflect what the patient is presently doing regarding the guidelines. Other wellness visits including but not limited to dental and eye exams.

ROS

(put N/A in sections not completed day of exam) Constitutional
Head
Eyes
Ears, Nose, Mouth, Throat
Neck
Cardiovascular/Peripheral Vascular
Respiratory
Breast
Gastrointestinal
Genitourinary
Musculoskeletal
Integumentary
Neurological
Psychiatric (screening tools: Ex: PHQ-9, MMSE, GAD-7)
Endocrine
Hematologic/Lymphatic
Allergic/Immunologic
Other

O: OBJECTIVE DATA
VITALS: HR: RR: BP: Temp:
SpO2%: Ht: Wt: BMI:
Age: LMP: PAIN:

PHYSICAL EXAM

(Pertinent data related to presenting problem or visit type. Put N/A in sections not completed day of exam) General Appearance
Head
Eyes
ENT, Mouth
Neck
Cardiovascular/Peripheral Vascular
Respiratory
Breast
Gastrointestinal
Genitourinary Male
• External Exam
• Internal Exam
Genitourinary Female
• External Exam
• Internal Exam
Musculoskeletal
Integumentary
Neurological
Psychiatric
Endocrine
Hematologic/Lymphatic
Allergic/Immunologic
Other

A: ASSESSMENT AND DIAGNOSIS
DIAGNOSIS ICD-10 CODES
PRIORITIZE DIAGNOSIS 1.
2.
3.

VISIT CODES CPT BILLING CODES
DIAGNOSTICS
POC TESTING
TESTS REVIEWED

P: PLAN
ACTIONS 1. Diagnosis:

Diagnostics Order: labs, diagnostics testing (tests that you planned for/ordered during the encounter that you plan to review/evaluate relative to your work up for the patient’s chief complaint.)

Therapeutic: changes in meds, skin care, counseling, include full prescribing information for any pharmacologic interventions including quantity and number of refills for any new or refilled medications. (Ex: Amoxicillin 500mg, PO, q12h, x 7 days, #14, no refills)

Education: information clients need in order to address their health problems. Include follow-up care. Anticipatory guidance and counseling.

Consultation/Collaboration: referrals or consult while in clinic with another provider. If no referral made was there a possible referral you could make and why? Advance care planning.

2. Diagnosis:

Diagnostics Order:

Therapeutic:

Education:

Consultation/Collaboration:

3. Diagnosis:

Diagnostics Order:

Therapeutic:

Education:

Consultation/Collaboration:

PREVENTITIVE

(Used for comprehensive exams)

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Tags: Headache, Migraine, Neurology, NU610 Unit 1 Case Study A 19-year-old female presents with a complaint of headaches frequently, Pain Management