Heidi, a 23-year-old woman, is a long-term patient of yours. She presents today with increasingly frequent headaches for the past three months associated with vomiting. Prior to this she had only occasional headaches, and they always resolved spontaneously or with simple analgesia, and didn’t require time off work or study. She is a third-year medical student and is coming up to her end-of-year exams.
Communication and Consultation Skills
Question: What elements of the history might change the communication style you use with Heidi? How would you change your communication if Heidi were from a non-English speaking background? What if she were an Aboriginal or Torres Strait Islander?
Answer:
- History Elements Affecting Communication Style:
- Stress and Anxiety: As a medical student nearing exams, Heidi may be experiencing significant stress. Using a calm and reassuring tone and validating her concerns will be important.
- Frequency and Severity of Symptoms: Frequent and severe symptoms necessitate a more urgent and empathetic approach, ensuring Heidi feels heard and understood.
- Impact on Daily Life: Understanding how headaches affect her studies and daily activities will guide a supportive and empathetic communication style.
- Communication for Non-English Speaking Background:
- Use of Interpreter: Utilize a professional interpreter to ensure clear and accurate communication.
- Simple Language: Avoid medical jargon and use simple, clear language.
- Visual Aids: Incorporate visual aids or diagrams to explain concepts and treatment plans.
- Communication for Aboriginal or Torres Strait Islander Patients:
- Cultural Sensitivity: Show respect for cultural practices and beliefs. Engage with cultural liaison officers if available.
- Building Rapport: Spend extra time building trust and rapport, as trust in healthcare providers may vary based on past experiences.
- Family Involvement: Involve family members in the consultation if appropriate and with Heidi’s consent.
Clinical Information Gathering and Interpretation
Question: What else do you need to ask about? What are the key elements of the history? What elements of the history will help you to distinguish between different types of headaches, such as migraine and tension headache? What examination would you perform? How would you vary your examination for different age groups, for example, a child compared to an older person? What are the red flags for this presentation?
Answer:
- Key Elements of the History:
- Headache Onset and Duration: Sudden or gradual onset, duration of headaches.
- Pattern and Frequency: Any changes in pattern or frequency over time.
- Character of Pain: Description of the pain (throbbing, sharp, dull).
- Associated Symptoms: Nausea, vomiting, photophobia, phonophobia, aura, neurological symptoms.
- Triggers: Possible triggers such as stress, certain foods, hormonal changes.
- Impact on Function: Effect on daily activities, work, and study.
- Medical History: Previous headache history, medications, and family history of headaches or migraines.
- History to Distinguish Headache Types:
- Migraine: Throbbing pain, often unilateral, associated with nausea, vomiting, and sensitivity to light and sound.
- Tension Headache: Bilateral, pressing or tightening pain, usually mild to moderate intensity, not aggravated by routine physical activity.
- Cluster Headache: Severe, unilateral pain around the eye, with associated autonomic symptoms like tearing, nasal congestion.
- Examination:
- General Examination: Vital signs, including blood pressure and temperature.
- Head and Neck Examination: Palpation of the head, neck, and shoulders for tenderness.
- Neurological Examination: Cranial nerves, motor and sensory function, reflexes, coordination, and gait.
- Examination Variations for Different Age Groups:
- Children: Focus on non-verbal cues, behavior changes, and parental observations.
- Older Adults: Comprehensive assessment for temporal arteritis (palpate temporal arteries), and consider underlying chronic diseases.
- Red Flags:
- Sudden Onset: Thunderclap headache.
- Neurological Symptoms: Weakness, vision changes, confusion.
- Systemic Symptoms: Fever, weight loss.
- New Headache Pattern: Especially in patients over 50.
- Worsening Pattern: Increasing frequency or severity.
Making a Diagnosis, Decision Making and Reasoning
Question: If you were considering a diagnosis of sex/orgasm headache, what serious conditions would you need to exclude before making this diagnosis? What findings in the history and examination would lead you to suspect raised intracranial pressure? In what circumstances would you request imaging? What is the most appropriate form of imaging?
coital cephalalgia or orgasmic headaches, are headaches associated with sexual activity, typically occurring during sexual excitement or at the moment of orgasm.
Types:
- Preorgasmic Headache:
- Characteristics: Dull, bilateral pain that increases with sexual excitement. It is often described as a tension-type headache.
- Onset: Gradual, building up as sexual arousal increases.
- Orgasmic Headache:
- Characteristics: Sudden, severe, explosive headache occurring at the moment of orgasm. It is often described as a thunderclap headache.
- Onset: Abrupt, at the peak of sexual activity or orgasm.
Symptoms:
- Preorgasmic Headache: Gradual onset of a dull, aching pain in the head and neck.
- Orgasmic Headache: Sudden, intense pain, often described as the worst headache ever experienced, coinciding with orgasm.
Serious Conditions to Exclude:
- Subarachnoid Hemorrhage: Sudden onset, severe headache.
- Intracranial Mass: Progressive headaches, focal neurological deficits.
- Cerebral Venous Thrombosis: Headache with neurological symptoms, visual disturbances.
- Findings Suggestive of Raised Intracranial Pressure:
- History: Headaches worse in the morning, with coughing or straining, associated with vomiting.
- Examination: Papilledema on fundoscopy, focal neurological signs, altered mental status.
- Circumstances for Imaging:
- Red Flags Present: Sudden onset, neurological deficits, systemic symptoms, altered mental status.
- Suspicion of Serious Pathology: Based on history and physical examination findings.
- Most Appropriate Form of Imaging:
- Initial Imaging: Non-contrast CT scan of the head for acute, severe headaches.
- Further Evaluation: MRI of the brain for detailed assessment if CT is inconclusive or if there’s a high suspicion of an intracranial mass or other pathology.
Clinical Management and Therapeutic Reasoning
Question: After assessing Heidi, it is apparent that the headaches are brought on by sexual intercourse. How would you manage sex/orgasm headache? What would your management be if your diagnosis were migraine, tension headache, or cluster headache? When would you refer and who would you refer to? Would you manage the situation differently in a rural or remote location with no local neurologist?
Answer:
- Management of Sex/Orgasm Headache:
- Acute Treatment: NSAIDs or triptans taken before sexual activity.
- Preventive Measures: Beta-blockers or calcium channel blockers if headaches are frequent.
- Reassurance and Education: Explain the benign nature of the condition and provide strategies to manage stress.
- Management of Other Headache Types:
- Migraine: Triptans, NSAIDs, antiemetics for acute attacks; beta-blockers, antiepileptics, or CGRP inhibitors for prevention.
- Tension Headache: NSAIDs or acetaminophen for acute relief; stress management techniques, regular physical activity.
- Cluster Headache: Oxygen therapy, sumatriptan injections for acute attacks; verapamil for prevention.
| Type of Headache | Classical Symptoms | Signs | Diagnosis | Treatments |
|---|---|---|---|---|
| Migraine | – Moderate to severe, typically unilateral – Throbbing or pulsating pain – Duration: 4 to 72 hours – Associated symptoms: nausea, vomiting, photophobia, phonophobia – May have aura (visual disturbances, sensory changes) | – Neurological examination usually normal – May have signs of distress during an attack | – Clinical diagnosis based on history – International Classification of Headache Disorders (ICHD) criteria | Acute Treatment: – NSAIDs (e.g., ibuprofen) – Triptans (e.g., sumatriptan) – Anti-emetics (e.g., metoclopramide) Preventive Treatment: – Beta-blockers (e.g., propranolol) – Antiepileptics (e.g., topiramate) – CGRP inhibitors (e.g., erenumab) |
| Tension Headache | – Bilateral, pressing or tightening pain – Mild to moderate intensity – No aggravation by routine physical activity – Duration: 30 minutes to 7 days | – Neurological examination normal – Muscle tenderness in head, neck, or shoulders may be present | – Clinical diagnosis based on history – ICHD criteria | Acute Treatment: – NSAIDs (e.g., ibuprofen) – Acetaminophen (paracetamol) Preventive Treatment: – Tricyclic antidepressants (e.g., amitriptyline) – Stress management techniques – Regular physical activity |
| Cluster Headache | – Severe, unilateral pain around the eye – Duration: 15 minutes to 3 hours – Associated autonomic symptoms (tearing, nasal congestion, ptosis, miosis) – Occurs in clusters (daily attacks for weeks to months, followed by remission) | – Horner’s syndrome (ptosis, miosis) – Lacrimation, nasal congestion on the affected side | – Clinical diagnosis based on history – ICHD criteria – MRI to rule out secondary causes | Acute Treatment: – Oxygen therapy (100% oxygen at 12-15 L/min) – Triptans (e.g., sumatriptan injections) Preventive Treatment: – Verapamil – Corticosteroids (short-term) – Lithium |
| Occipital Neuralgia | – Sharp, shooting pain in the distribution of the greater occipital nerve – Pain usually unilateral, originating in the neck and spreading to the back of the head | – Tenderness over the greater occipital nerve – Pain on palpation | – Clinical diagnosis based on history and physical exam – MRI to rule out structural lesions | Acute Treatment: – NSAIDs – Local anesthetic nerve blocks Preventive Treatment: – Antiepileptic drugs (e.g., gabapentin) – Tricyclic antidepressants – Occipital nerve blocks |
| Cervicogenic Headache | – Unilateral headache – Pain originates in the neck, radiates to the front of the head – Associated with neck movement or posture | – Restricted range of motion in the neck – Tenderness over the cervical spine and occipital regions | – Clinical diagnosis based on history and physical exam – Diagnostic nerve blocks may confirm the diagnosis | Acute Treatment: – NSAIDs – Physical therapy Preventive Treatment: – Physical therapy – Nerve blocks – Radiofrequency ablation |
| Medication Overuse Headache | – Headache occurring on 15 or more days per month – Regular overuse of acute headache medication (e.g., triptans, NSAIDs, opioids) for more than 3 months – Typically presents with a mix of migraine-like and tension-type headache symptoms | – Often no specific findings on neurological examination | – Clinical diagnosis based on history of medication use and headache frequency – ICHD criteria | Management: – Educate the patient about the condition – Gradual withdrawal of overused medications – Bridge therapy (e.g., prednisone) may be used during withdrawal – Initiate preventive treatments (e.g., topiramate, amitriptyline) – Cognitive behavioral therapy (CBT) and stress management techniques |
- Referral and Specialist Consultation:
- When to Refer: Persistent or severe headaches not responding to treatment, red flags, complex cases.
- Specialists to Refer To: Neurologist, headache specialist.
- Rural/Remote Management: Use telehealth services for specialist consultations, collaborate with local healthcare providers.
Preventive and Population Health
Question: If your diagnosis were tension headache, and Heidi told you that at least five other students in her year were having similar symptoms, with headaches becoming more severe and frequent around exam time, what could you do in partnership with the medical school to prevent/address this issue?
Answer:
- Partnership with Medical School:
- Stress Management Workshops: Organize workshops on stress management, relaxation techniques, and time management.
- Counseling Services: Promote access to counseling services and mental health support.
- Healthy Lifestyle Promotion: Encourage regular exercise, healthy eating, adequate sleep.
- Peer Support Groups: Facilitate peer support groups for students to share experiences and coping strategies.
Professionalism
Question: You work in a rural practice, and also at the rural clinical school where Heidi is a student. How would you manage the patient–doctor relationship and protect confidentiality? How might you manage the situation if the diagnosis were tension headache, but Heidi insisted on further investigation, including an MRI? What if she requested special consideration for exams? How do you maintain boundaries?
Answer:
- Managing Patient–Doctor Relationship and Confidentiality:
- Clear Boundaries: Maintain professional boundaries by treating Heidi as you would any other patient.
- Confidentiality: Ensure that all discussions and medical records are kept confidential, especially in a small community setting.
- Handling Requests for Further Investigation:
- Evidence-Based Practice: Explain the rationale for not ordering unnecessary tests if clinical findings do not indicate a need for an MRI.
- Patient Education: Provide thorough education about tension headaches and why further investigation may not be needed.
- Consideration for Exams: Assess the severity of her symptoms and their impact on her ability to perform. If justified, provide appropriate documentation for special consideration.
- Maintaining Boundaries:
- Professionalism: Keep interactions strictly professional, avoiding any influence of the academic relationship on clinical decisions.
- Transparency: Be transparent with Heidi about the reasons for your clinical decisions, maintaining trust and clarity.
General Practice Systems and Regulatory Requirements
Question: Thinking of the broader differential diagnoses, are there any that would require a mandatory report to AHPRA? What are the Medicare rebate requirements for an MRI of the head? Heidi asks you for a medical certificate for special consideration for her exams, based on recurrent severe headaches. How would you approach this situation?
Answer:
- Mandatory Reporting to AHPRA:
- Conditions Requiring Reporting: Significant impairment that affects the ability to practice safely, substance abuse issues, severe psychiatric conditions.
- Medicare Rebate Requirements for MRI of the Head:
- Eligibility Criteria: Headaches with specific red flags such as sudden onset, focal neurological signs, or suspicion of a serious pathology.
- Issuing a Medical Certificate:
- Assessment: Conduct a thorough assessment to ensure the request is medically justified.
- Documentation: Provide detailed documentation outlining the severity and impact of the headaches on her exam performance.
- Support: Offer additional support or recommendations to help manage her condition and reduce the impact on her studies.
Procedural Skills
Question: In which situations would you consider an occipital nerve block?
Answer:
- Indications for Occipital Nerve Block:
- Chronic Migraine: When other treatments have failed or are contraindicated.
- Occipital Neuralgia: Characterized by sharp, shooting pain in the distribution of the greater occipital nerve.
- Refractory Tension Headaches: When conservative treatments have not provided adequate relief.
Managing Uncertainty
Question: What initial management would you consider if the cause of Heidi’s headaches was not clear? Would you order a CT/MRI of the head if the cause seemed benign, but you were still uncertain as to the diagnosis?
Answer:
- Initial Management:
- Symptomatic Treatment: NSAIDs, acetaminophen, antiemetics.
- Lifestyle Modifications: Stress management, adequate hydration, regular sleep patterns.
- Monitoring: Regular follow-up to monitor symptom progression and response to treatment.
- Imaging Consideration:
- CT/MRI: If initial management does not provide relief, and there is ongoing uncertainty about the diagnosis, consider imaging to rule out serious underlying conditions.
- Criteria for Imaging: Persistent headaches despite treatment, new or worsening symptoms, or presence of red flags.
- CT Brain:: Risk of Developing Cancer and Comparison with Background Radiation
- Amount of Radiation from CT Brain: The typical effective dose from a CT brain scan is approximately 2 millisieverts (mSv).
- Comparison with Background Radiation and Other Sources
- Background Radiation:
- The average person is exposed to about 3 mSv of background radiation per year, which comes from natural sources like cosmic rays, radon gas, and terrestrial sources.
- Radiation from Flying:
- Flying exposes passengers to increased levels of cosmic radiation. For example:
- 7-hour flight: Approximately 0.03 mSv.
- Therefore, a CT brain scan (2 mSv) is equivalent to roughly 66 hours of flying (or approximately 9-10 long-haul flights).
- Flying exposes passengers to increased levels of cosmic radiation. For example:
- Background Radiation:
- Risk of Developing Cancer from CT Brain
- Cancer Risk:
- The risk of developing cancer from radiation is often measured in terms of additional lifetime risk.
- For a typical adult, the estimated additional lifetime risk of developing cancer from a single CT brain scan is about 1 in 10,000 to 1 in 2,000.
- This risk is considered low, especially when compared to the diagnostic benefits of the scan.
- Cancer Risk:
- Evidence and Research
- Studies and Reports:
- Health Physics Society: Reports that the risk from a single CT scan is small but acknowledges that the cumulative effect of multiple scans can increase the risk.
- National Cancer Institute: Provides data on the radiation doses from various medical imaging procedures and estimates the associated cancer risks.
- BMJ Study (2012): A study published in the BMJ indicated that cumulative radiation exposure from multiple CT scans in children can increase the risk of leukemia and brain tumors. However, this risk remains low, and the study emphasizes the importance of judicious use of CT scans.
- Studies and Reports:
- Regulatory Guidelines:
- ALARA Principle (As Low As Reasonably Achievable): Radiology guidelines emphasize minimizing radiation exposure by using the lowest dose necessary to achieve a diagnostic result.
- ACR Appropriateness Criteria: The American College of Radiology provides criteria to ensure CT scans are used appropriately and when benefits outweigh the risks.
- Summary
- Radiation Dose: A CT brain scan delivers approximately 2 mSv of radiation.
- Comparison: This dose is equivalent to about two-thirds of a year of natural background radiation or around 66 hours of flying.
- Cancer Risk: The additional lifetime risk of developing cancer from a single CT brain scan is estimated to be low, ranging from 1 in 10,000 to 1 in 2,000.
- Evidence: Studies and guidelines emphasize the importance of using CT scans judiciously and following protocols to minimize radiation exposure while ensuring diagnostic benefits.
Identifying and Managing the Significantly Ill Patient
Question: On examination, you find that Heidi has a temperature of 38.2 degrees Celsius and is unable to flex her neck. How does this change your management? What are the essential first steps in management? What are the red flags that would prompt you to refer urgently to a higher level of care?
Answer:
- Changed Management Due to Findings:
- Immediate Concern: Suspect meningitis or other serious central nervous system infection.
- Initial Steps:
- Urgent Referral: Immediate referral to the emergency department.
- Empirical Antibiotics: Administer empirical antibiotics if meningitis is strongly suspected.
- Essential First Steps in Management:
- Stabilization: Ensure airway, breathing, and circulation are stable.
- Diagnostic Testing: Blood cultures, lumbar puncture (if safe and available), and imaging if indicated.
- Red Flags for Urgent Referral:
- Severe Headache: Sudden onset, thunderclap headache.
- Neurological Deficits: Any focal neurological signs.
- Systemic Symptoms: Fever, weight loss, night sweats.
- Signs of Raised Intracranial Pressure: Papilledema, altered mental status.
By addressing these aspects thoroughly, you can ensure a comprehensive and effective approach to managing Heidi’s headaches in a general practice setting.