jmj11 Posted November 16, 2012 Share Posted November 16, 2012 Okay, I'm seeing a 28 year old woman, who was in an excellent state of health until July. She awaken with a global headache with slight photophobia but no other associated symptoms. The headache has never gone away and if anything is worsening over time and now average 6-7/10 constantly. To cut to the chase, she was followed by a local neurologist. She had CT (ER) and MRI, both normal. She was diagnosed by the neurologist as "stress headaches" and placed on butalbital. Her PCP then referred her to me. I will mention that her exam was completely normal, she doesn't appear ill but a little uncomfortable, as were her vital signs normal. Her ROS was also completely benign except for the headaches. Her PMHx is also benign except of a long history of ADHD and is on Adderall (for >10 years). Her family history is negative for headaches. She had been tried on several headache preventative and abortive medications with no benefit. Now, the diagnoses is easy according the International Headache Society Criteria . . . New Daily Persistent Headache. However that is more of a label than a description of pathophysiology. I have a plethora of NDPH patients. However, I always work hard to rule out a primary cause. Every disease state can present as headache. I had a gal like her five years ago that turned out to have lymphoma and headache was her presenting symptom. Here is where you can make suggestions. I ordered my basic headache labs. CBC and lytes fine. TSH, T3, T4 all fine. But, her Sed rate was 32 and her CRP was 2.89. I'm repeated those in a couple of weeks looking for a trend or fluke. Remember she has no other symptoms including inflammatory type symptoms. I ordered a spinal tap but the local hospital (I'm seeing her at my remote site) refused my orders. Now she has to come down to my hospital on my island and get it next week. I want to look at opening pressures, cells and etc. This will probably remain as NDPH, but anything else you would look for with the elevated sed rate and CRP? I may order an MR-V, which hasn't been done. Link to comment Share on other sites More sharing options...
Moderator LT_Oneal_PAC Posted November 16, 2012 Moderator Share Posted November 16, 2012 Giant cell arteritis? Just spit balling. It would be pretty rare in her age Link to comment Share on other sites More sharing options...
rcdavis Posted November 16, 2012 Share Posted November 16, 2012 ^^^ I think it is almost reportable for a dx of GCA in anyone under 50. Mike, another stretch, but how about a rheumatologist /immunologic screen for Lupus or collagen vascular etio? And a UA. Also, to r/o hepatic origin ( hep c, chronic active hepatitis, Wilson's, PBS, etc- all of which can present with headache) I would add a Cmp and hepatic profile. And an Rpr. If all those are neg ( I'll bet the ANA, ANCA, antiSs etc will be positive) ya gotta LP.. To r/o primary CNS lymphoma, etc. Link to comment Share on other sites More sharing options...
jmj11 Posted November 16, 2012 Author Share Posted November 16, 2012 Giant cell arteritis? Just spit balling. It would be pretty rare in her age I think it would make the cover of Headache if it was (youngest case I've ever seen was 57). Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted November 16, 2012 Moderator Share Posted November 16, 2012 ^^^ I think it is almost reportable for a dx of GCA in anyone under 50. Mike, another stretch, but how about a rheumatologist /immunologic screen for Lupus or collagen vascular etio? And a UA. Also, to r/o hepatic origin ( hep c, chronic active hepatitis, Wilson's, PBS, etc- all of which can present with headache) I would add a Cmp and hepatic profile. And an Rpr. If all those are neg ( I'll bet the ANA, ANCA, antiSs etc will be positive) ya gotta LP.. To r/o primary CNS lymphoma, etc. I was thinking a rheum d/o as well. Link to comment Share on other sites More sharing options...
jmj11 Posted November 16, 2012 Author Share Posted November 16, 2012 I was thinking a rheum d/o as well. When I repeat my labs next week, and if still elevated sed rate, I was just going to refer her to the rheumatologist for a close work up. But no join pain, rashes, and I even thought about Wegner's but no symptoms. Link to comment Share on other sites More sharing options...
Guest Paula Posted November 17, 2012 Share Posted November 17, 2012 Did you think of Lyme, Erlichiosis or Babesiosis screening? Link to comment Share on other sites More sharing options...
Guest JMPA Posted November 17, 2012 Share Posted November 17, 2012 Okay, I'm seeing a 28 year old woman, who was in an excellent state of health until July. She awaken with a global headache with slight photophobia but no other associated symptoms. The headache has never gone away and if anything is worsening over time and now average 6-7/10 constantly. To cut to the chase, she was followed by a local neurologist. She had CT (ER) and MRI, both normal. She was diagnosed by the neurologist as "stress headaches" and placed on butalbital. Her PCP then referred her to me. I will mention that her exam was completely normal, she doesn't appear ill but a little uncomfortable, as were her vital signs normal. Her ROS was also completely benign except for the headaches. Her PMHx is also benign except of a long history of ADHD and is on Adderall (for >10 years). Her family history is negative for headaches. She had been tried on several headache preventative and abortive medications with no benefit. Now, the diagnoses is easy according the International Headache Society Criteria . . . New Daily Persistent Headache. However that is more of a label than a description of pathophysiology. I have a plethora of NDPH patients. However, I always work hard to rule out a primary cause. Every disease state can present as headache. I had a gal like her five years ago that turned out to have lymphoma and headache was her presenting symptom. Here is where you can make suggestions. I ordered my basic headache labs. CBC and lytes fine. TSH, T3, T4 all fine. But, her Sed rate was 32 and her CRP was 2.89. I'm repeated those in a couple of weeks looking for a trend or fluke. Remember she has no other symptoms including inflammatory type symptoms. I ordered a spinal tap but the local hospital (I'm seeing her at my remote site) refused my orders. Now she has to come down to my hospital on my island and get it next week. I want to look at opening pressures, cells and etc. This will probably remain as NDPH, but anything else you would look for with the elevated sed rate and CRP? I may order an MR-V, which hasn't been done. I may be just her adderall, i would also consider dietary causes. Link to comment Share on other sites More sharing options...
PA4me2010! Posted November 17, 2012 Share Posted November 17, 2012 This may be a very basic question, and seeing that I'm not out of school just yet, I don't have much to offer. Is it possible that she could be pregnant? Or any other gynecological issue? Link to comment Share on other sites More sharing options...
Moderator ventana Posted November 17, 2012 Moderator Share Posted November 17, 2012 Eye exam? eye fatigue - new computer or TV watching? keratitis? new living place or enviro allergies? trial flonase just on the outside chance UCG is a resonable issue New smoker? or change in smoking Drug use? New job? cleaning agents? Nasal expsosure to something? tic born panel - lyme, bab, ehr reasonable to look at GGT on top of LFT's HSV I and II IgM IgG - new Dx with sub acute infection way out there - Flex/Ext c-spine films Honestly in a younger person - have then seen a by a really good PT that does atlantoAxial alignment "energy" work - craniosacral. Would lean more towards a muslce anatomy issue then anything else.... have a few great stories of younger people with chronic neck and head ache pain that were "cured" by therapy - BUT this needs to be a highly experienced PT or even a chiro if they have that special interest. This is not vudo or black majic or strange stuff but instead has great success - also not for a year of treatment 3x's per week - but instead they should be on schedule for only a few weeks to maybe a month. an SP brought up a strange thought the other day for a pain patient - "just try them on a medrol dose pack to see if it is any benefit" sort of throwing things against the wall to see if they stick..... Link to comment Share on other sites More sharing options...
jmj11 Posted November 17, 2012 Author Share Posted November 17, 2012 This may be a very basic question, and seeing that I'm not out of school just yet, I don't have much to offer. Is it possible that she could be pregnant? Or any other gynecological issue? Always a consideration in new headache syndromes if there is an hormonal change (like you suggest, I have seen young women who suddenly get worse headaches and either were pregnant and didn't know it or had just changed OCCs.). I raised hormonal questions. No changes. She is a lesbian and, I know that doesn't rule out pregnancy, but I asked her if there was any chance she was (such as insemination) and there is no chance. Plus, this headache has gone on for four months now and I think she would have figured that out by now. But her menses is regular. Link to comment Share on other sites More sharing options...
jmj11 Posted November 17, 2012 Author Share Posted November 17, 2012 I will answer no to all your questions, except that I have not done titers (except for cryptococcus). Regarding the PT cure, I've heard of headache "cures" for thirty years. I work in evidence based medicine and don't put a lot of stake in testimonials. When these "cures" are put through the rigors or placebo controlled testing, they almost always come out equivalent to the placebo effect. If something did "cure" any headache, and was proven to do so, they would make the cover of every headache journal in the world, be nominated for the Nobel prize in medicine, and become some of the wealthiest PTs on the planet with thousands of patients coming from all over the world to see them. Plus, I didn't get into these details but I can tell you her headaches are not cervicogenic by any stretch. Link to comment Share on other sites More sharing options...
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