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An 80-year-old female presents to the outpatient clinic complaining of headache in the bilateral frontal and temporal regions. She says the headache has been present for at least a couple of years, but has recently become worse over the past few months. It is described as squeezing in character with muscle tightness, graded around 8/10 in severity. She notes occasional nausea without vomiting. No sensitivity to light or sound is noted. She denies having any problems with vision, eye tearing, swallowing, or speech, or neck pain. No bladder or bowel movement problems are noted. No complaints of new numbness or weakness are noted. The headache occurs throughout most of the day, every day, and it can happen any time. She has a background of hip arthritis, with prior hip replacement, and has been on chronic oral narcotic therapy. Due to the increase in headache severity, she has been taking more of her pain medication, without much benefit.

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On examination, she is anxious and in mild distress due to the headache. She is afebrile, with a heart rate of 78 bpm and a blood pressure of 130/85 mm Hg. She is alert and oriented, and speech and expression are intact. Palpation of her temporal regions bilaterally does not elicit tenderness. Her face appears symmetric. Fundoscopy does not reveal papilledema. Cardiac examination and lung examination are normal. Normal sensory function is noted with light touch. Muscle strength is graded as 5/5 throughout with deep tendon reflexes 1+ throughout. There is pain with internal and external rotation of her right hip. Gait and stance including tiptoe and heel walking is normal, but unsteady on tandem walk. Romberg sign is negative. Finger-to-nose testing does not reveal ataxia.

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1. In light of her reported symptoms by history, what is the patient's most likely primary diagnosis?

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2. What may be the precipitating factor in this case?

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3. What management decision would you need to make at this time?

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Answers

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  1. The patient's baseline chronic headache seems to have worsened with her increased narcotic pain medication use, which she originally started for her arthritic pain. In light of her reported symptoms by history, and lack of other striking features on her history and examination, the patient's most likely primary diagnosis is a medication-overuse headache, with a likely underlying preceding tension-type headache (TTH).

  2. Narcotic pain medications are the likely precipitating factor.

  3. It would be reasonable to attempt a taper off of her narcotic pain medications and reassess her symptoms. Due to her age, it would be also appropriate to exclude secondary causes of her headache.

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Although the character of the patient's headache does not appear to suggest a very specific cause, her presentation forces one to think about the various potential causes of headache. Because of her advanced age, it is important ...

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