Note Migraine Headache

2 Week 7 SOAP Note: Migraine Headache ID Ariel Mermaid is an 18-year-old Caucasian female, DOB 1/1/2003, accompanied by her grandmother. The patient appears to be a reliable historian. Subjective CC: "I am here to establish care since my insurance just changed. I have also been getting really bad headaches about twice a month for the last three months. I just want to get checked out so I know nothing is wrong.” HPI A.M is an 18-year-old Caucasian female presenting with a PMH of ADHD for a chief complaint of moderate to severe unilateral headaches that occur one to two times a month for the last three months. Patient describes the headaches as throbbing, 6-8 out of 10 on a 1-10 pain scale, and occurring unilaterally in the temporal region and last 3-4 hours. Patient reports associated nausea and photophobia with the headaches, but denies auras, neck pain, fevers, and vision and hearing loss. Patient reports taking over the counter Tylenol and Ibuprofen for pain relief, as well as resting in a dark, quiet room when the headaches occur because bright lights and loud noises aggravate the headaches. Patient denies any known triggers for the headaches. Past Medical History: ● Medical: ○ ADHD ■ Patient reports being on medication for ADHD when she was younger, but was “forced” to stop all medications abruptly approximately 8 months ago by her mother who she was living with at the time. ○ Depression ○ Suicide attempt (2018) ○ Anxiety ○ Insomnia ○ Marijuana dependance ● Surgeries: ○ None ● Hospitalizations: ○ Suicide attempt (2018) ● Preventative care: ○ Covid vaccine – Not vaccinated ○ Eye exam: 3/1/2022 – Wears glasses ○ Dental exam: 2/1/2022 – Normal 3 ○ Pap smear: None Allergies:  Penicillin Medications:  OTC Tylenol 650 mg PO PRN 4-6 hours for pain/headaches  OTC Ibuprofen 400 mg PO PRN 6 hours for pain/headaches Social History:  ETOH: Reports rare alcohol consumption  Nicotine: Denies smoking nicotine  Drug use: Reports daily marijuana use for insomnia. Denies other recreational drug use.  Caffeine use: Reports 1-2 energy drinks daily  Sexual health: Reports being in a committed sexual relationship where condoms are the only source of contraception. However, the patient reports having 2 sex partners in the last year.  Employment: student  Living arrangement: Currently living with grandmother after having an argument with her mother who forced her to abruptly stop taking ADHD, depression, and anxiety medications. Family History:  Father is deceased from alcoholic liver cirrhosis.  Mother is living. Reports hx of bipolar, alcohol abuse, drug use, HTN, CAD. ROS   Constitutional: Denies fevers, fatigue, lightheadedness, and feeling unwell. Neurological: Reports unilateral headaches in the temporal region 6-8/10 that is throbbing. Denies aura, numbness and tingling in upper and lower extremities, trouble walking, confusion, or memory loss.  HEENT: Denies vision and hearing loss. Reports photophobia and phonophobia associated with headaches. Denies rhinorrhea, sore throat, ear ache, and flu like symptoms.  Cardiovascular: Denies tachycardia, chest pain, and lower extremity edema.  Pulmonary: Denies coughing, shortness of breath, and wheezing. Objective Vital Signs H 74 BP 125/82 RR 16 Temp 97.9 F R Heigh t SpO2 98% room air Pain 7/10 Right temporal headache 56 inches (142.24 cm) Weight 126 lbs. (54.43 kg) BMI 20.3 (normal) 4 Physical Exam  General survey: Mood and disposition appropriate. Well groomed. Follows commands.  Neurological: Alert and fully oriented. Patient denies numbness and tingling in bilateral upper and lower extremities. Reports unilateral headaches in the temporal region 68/10 that is throbbing. Denies aura and trouble walking. Short term and long-term memory intact. Gait normal. Gross and fine motor skills intact. Cranial nerves I-X intact.  HEENT: Pupils are equal and reactive to light. No papilledema noted. Red reflex seen. Tympanic membrane intact without swelling or redness. No nasal drainage noted. Mucous membranes moist. No tonsillar redness or swelling noted.  Cardiovascular: S1and S2 present. No abnormal heart sounds and rhythm noted during auscultation. Bilateral radial and dorsalis pedis pulses 2+. Absent leg swelling.  Pulmonary: Respiration rate normal. All lung sounds clear. No dyspnea noted. Labs, radiology, and other pertinent studies  Labs Because this patient is establishing care, a full panel of blood work should be ordered to assess the baseline health of the patient and to see if there are any indicators that could be contributing to her headaches such as anemia, infections, hypothyroidism, and vitamin deficiencies (Pippitt & Ozudogru, 2021).  CBC  CMP  Thyroid panel  Lipid panel  HgbA1C  STI screening  Vitamin B12 and Folate  Vitamin D  Magnesium  UA  Diagnostic testing Neuroimaging such as an MRI of the brain is not needed on this patient because she is not showing signs or symptoms of a cerebral vascular accident, is not having prolonged or bizarre auras, has not experienced loss of conscientiousness with her headaches, and is not having any other neurological symptoms (Pippitt & Ozudogru, 2021). Assessment Differentials 1. Migraine, unspecified, not intractable, without status migrainosus [ICD-10: G43.909] a. The symptoms of the headache, including unilateral throbbing, associated nausea, photophobia, phonophobia, and duration lasting a few hours indicate that the patient is likely experiencing migraine headaches (Cutrer, 2022). Furthermore, the patient’s risk factors of female gender, insomnia, caffeine overuse, and history of 5 depression and anxiety make the diagnosis of migraine headaches more likely compared to the other differential diagnoses (Pippitt & Ozudogru, 2021). 2. Drug induced headache, not elsewhere classified, not intractable [ICD-10: G4.40] a. Marijuana use has been known to cause headaches (Mayo Clinic, 2020). Furthermore, caffeine is also known to trigger headaches (Tornstrom, 2020). Because this patient reports daily marijuana and caffeine use, she could be experiencing drug induced headaches. However, because she only experiences headaches one to two times a month, migraine headaches are more likely the diagnosis. 3. Tension type headache, unspecified, not intractable [ICD-10: G44.209] a. Tension headaches are the most common type of headache that can be triggered by caffeine and marijuana use, sleep disturbances, stress, hormonal changes, and physical exertion (AlAbdulKader & Chao, 2021). While the patient reports experiencing many of these symptoms and triggers, tension headaches are generally located in bilateral areas of the head and described as a “bandlike pressure,” making tension headaches a less likely diagnosis (AlAbdulKader & Chao, 2021). Plan Diagnosis 1. Migraine, unspecified, not intractable, without status migrainosus [ICD-10: G43.909] a. Laboratory blood work i. CBC: Assess for anemia and possible indication of an infection ii. CMP: Assess electrolytes, possible dehydration, and kidney and liver function iii. Thyroid panel: Assess for hypothyroidism and hyperthyroidism iv. Lipid panel: Assess for hyperlipidemia and hypertriglyceridemia for cardiac risk factors v. HgbA1C: Assess for diabetes vi. STI screening: Assess for sexually transmitted diseases because the patient reports having multiple partners in the last year. vii. Vitamin B12 and Folate: Assess for Vitamin B deficiency and anemia viii. Vitamin D: Assess for vitamin D deficiency ix. Magnesium: Assess for hypomagnesemia and hypermagnesemia x. Urine analysis: Assess for a urinary tract infection, protein in the urine, and glucose in the urine. b. Diagnostic tests i. Use a validated migraine screening tool (Pippitt & Ozudogru, 2021). 6 1. If patients answer yes to 2-3 questions on the migraine screening tool, there is an 81-93% chance that they ae experiencing migraine headaches (Pippitt & Ozudogru, 2021). ii. Referral to OBGYN for pap smear, hormone evaluation, and contraception counseling per patient request. c. Medications i. Continue Tylenol 650 mg PO every 4-6 hours PRN to abort mild migraine headache (Pippitt & Ozudogru, 2021). ii. Start sumatriptan 100 mg PO PRN to abort moderate to severe migraine headache. Can repeat dose in 2 hours for a max dose of 200 mg in 24 hours (Pippitt & Ozudogru, 2021). iii. Magnesium 400 mg PO daily -if magnesium level is not high (Pippitt & Ozudogru, 2021). iv. Melatonin 3 mg PO nightly (Pippitt & Ozudogru, 2021) d. Nonpharmacologic treatment i. Cold compresses to affected area. ii. Remove self from stressful situations. iii. Reduce or abstain from caffeine consumption (Pippitt & Ozudogru, 2021). iv. Marijuana cessation (Pippitt & Ozudogru, 2021). v. Maintain good sleep hygiene (Pippitt & Ozudogru, 2021). e. Patient education i. Avoid estrogen-based medications due to an increased risk of stroke (Pippitt & Ozudogru, 2021). ii. Maintain a headache log which should include “episodes per month, headache days per month, frequency, and amount and effect of medications used (Pippitt & Ozudogru, 2021, p. 430).” iii. Identify possible triggers and avoid them. iv. If you experience more than 10 headaches per month, return to the clinic for evaluation. v. Exercise and staying active will help with mental health, ADHD symptoms, and headache prevention. vi. Stay hydrated. vii. Avoid overly stressful situations and find healthy ways to manage stress. viii. Avoid caffeine and marijuana use. ix. Avoid alcohol x. Use condoms to prevent STIs. f. Follow up i. Follow up appointment in 2 weeks to review laboratory results, then every 3 months to monitor frequency and severity of headaches.