A 34-year-old female presents with a 3-day history of progressive frontal headache, rated 7/10 in severity. The headache is throbbing in nature, worse in the morning, and partially relieved by over-the-counter ibuprofen. She also reports mild nausea and photophobia. Patient is a known diabetic and hypertensive on treatment. No history of trauma, fever, or visual changes.
History of Presenting Illness
- Onset: 3 days ago, gradual onset during work hours
- Character: Throbbing, predominantly frontal; occasionally radiates to temporal regions
- Aggravating factors: Bright lights, stress, prolonged screen time, early morning
- Relieving factors: Rest, dark room, ibuprofen 400mg (partial relief for 3-4 hours)
- Associated symptoms: Mild nausea (no vomiting), photophobia, poor sleep quality (4-5 hrs/night for 2 weeks)
- Negative history: No fever, no visual disturbances, no limb weakness, no seizures, no neck stiffness
- PMH: T2DM (Jan 2024) on Metformin 500mg BID, HTN (Jun 2022) on Losartan 50mg + Amlodipine 5mg daily
- Drug allergy: Penicillin (anaphylaxis)
- General: Alert, oriented, mildly uncomfortable. Not in acute distress. BMI 26.4
- Vitals: BP 152/94 mmHg (elevated), HR 88 bpm regular, Temp 36.8°C, RR 16/min, SpO2 98% RA
- HEENT: PERRLA. No papilledema on fundoscopy. Frontal sinus tenderness bilaterally. Oropharynx clear, no neck stiffness
- CNS: Cranial nerves II-XII intact. No focal neurological deficits. Power 5/5 all limbs. DTR 2+ bilaterally. Gait normal
- CVS: S1 S2 heard, no murmurs. No peripheral oedema. JVP not elevated
- Respiratory: Clear breath sounds bilaterally. No wheeze or crepitations
- Abdomen: Soft, non-tender, no organomegaly. Bowel sounds present
- Primary: Tension-type headache (G44.2) — likely stress-related with possible migraine overlap
- Secondary: Hypertension, uncontrolled (I10) — BP 152/94 despite current dual-agent therapy
- Ongoing: Type 2 Diabetes Mellitus (E11.9) — suboptimal control, HbA1c 7.2%
- Investigations: CBC, BMP, HbA1c (stat). CT Head without contrast if symptoms persist beyond 1 week
- Medication changes: Uptitrate Losartan from 50mg to 100mg daily; add Sumatriptan 50mg PRN for acute headache
- Non-pharmacological: Sleep hygiene counselling, stress management, headache diary, limit screen time
- Monitoring: BP re-check in 2 weeks; home BP monitoring log; HbA1c review
- Referral: Ophthalmology review if headache persists or visual symptoms develop; Diabetic clinic follow-up in 4 weeks
- Patient education: Discussed diagnosis, medication compliance, lifestyle modifications, and red flag symptoms to return for
- Follow-up: Return in 2 weeks for BP and lab review. Sooner if headache worsens or new symptoms