the killer headache case study answers quizlet

Case Study The Killer Headache Chemistry and Toxicology PRINT and DIGITAL

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FORENSIC SCIENCE DISTANCE LEARNING! In this Cross Curricular Active Reading Case Study Article, the focus is on FORENSIC CHEMISTRY & TOXICOLOGY. Students will study the perplexing case of The Killer Headache (Stella Nickell) & how forensic chemistry led to the discovery of cyanide tainted pills in 1986. This case is the perfect lead in to a unit of Forensic Chemistry or Toxicology, alternately use this case study as part of a unit studying serial killers.

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Chapter 20-1:  Approach to the Patient with Headache - Case 1

Jennifer Rusiecki

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Chief complaint, constructing a differential diagnosis.

• RANKING THE DIFFERENTIAL DIAGNOSIS
• MAKING A DIAGNOSIS
• CASE RESOLUTION
• Full Chapter
• Supplementary Content

Ms. M is a 34-year-old woman who comes to an outpatient practice complaining of intermittent headaches.

Figure 20-1.

Diagnostic approach: headache.

Headache is one of the most common physical complaints. Because < 1% of all headaches are life-threatening, the challenge is to reassure and appropriately treat patients with benign headaches while finding the rare, life-threatening headache without excessive evaluation.

Headaches are classified as primary or secondary. Primary headaches are syndromes unto themselves rather than signs of other diseases. Although potentially disabling, they are reliably not life-threatening. Secondary headaches are symptoms of other illnesses. Unlike primary headaches, secondary headaches are potentially dangerous.

The distinction between primary and secondary headaches is useful diagnostically. Primary headaches, such as tension headaches, are diagnosed clinically, sometimes using diagnostic criteria (the most commonly used are published by the International Headache Society, IHS). Traditional diagnostic studies (laboratory studies, radiology, pathology) cannot verify the diagnosis. Secondary headaches, such as headaches caused by central nervous system (CNS) tumors, often can be definitively diagnosed by identifying the underlying disease of which the headache is a symptom.

Clinically, primary and secondary headaches can be difficult to distinguish. The single most important question when developing a differential diagnosis for a headache is, “Is this headache new or old?” Chronic headaches tend to be primary, while new-onset headaches are more likely to be secondary. This is the first and most important pivotal point in diagnosing headaches. This distinction is not perfect. There are some chronic headaches that are secondary headaches (headaches caused by cervical degenerative joint disease for example) and even classic, primary headaches (such as migraines) can present as a new headache. The differentiation of old versus new also depends on how rapidly a patient brings his or her symptoms to medical attention. This being said, the classification of headaches as primary versus secondary and new versus old provides not only a memorable framework for the differential diagnosis but also a clinically useful structure by which the differential can be organized by pivotal points. The differential diagnosis appears below. Figure 20-1 shows the potential diagnoses in a more algorithmic form as they are often considered clinically. The IHS’s classification website ( https://www.ichd-3.org/ ) is also a terrific resource for an annotated differential diagnosis.

Old headaches

Tension headaches

Migraine headaches

Cluster headaches

Cervical degenerative joint disease

Temporomandibular joint syndrome

Cranial neuralgias (maybe either primary or secondary)

Headaches associated with substances or their withdrawal

Analgesics (often presenting as chronic daily headaches)

New headaches

Benign cough headache

Benign exertional headache

Headache associated with sexual activity

Benign thunderclap headache

Idiopathic intracranial hypertension (pseudotumor cerebri)

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Putting your headache knowledge to practice with three clinical cases

Headache clinical case #1

A 46-year-old woman comes to see you complaining of headaches. The headaches occur mostly, but not always, at the left forehead and temple. The character of the pain is pulsating, and she grades the severity as 7–8 out of 10.

The headaches start after she experiences a visual cloud appearing toward the right visual field, which grows and moves across her vision before disappearing within 15 minutes. Her headaches last for several hours and are usually gone after she sleeps. She has about four of these headaches a month. She occasionally experiences nausea but no vomiting. She is unable to do her usual tasks as this increases the headache. Light bothers her eyes.

Characterizing the headache

The character of the headache pain, its severity, localization, and associated complaints are the keys to diagnosis of this clinical case.

Location: unilateral

Pain characteristics: throbbing

Intensity: severe

Associated complaints: nausea and photophobia, positive visual aura, and exacerbated by usual activity

This patient has the criteria to correctly diagnose a migraine headache with aura.

Approach to treatment

If her examination was otherwise normal, you do not need to order imaging, especially if she had headaches before.

Given the diagnosis of migraine headache with aura, you would have her identify potential migraine triggers and ask her to try to avoid those potential triggers. Have her download a smart phone headache diary app to allow her to record details of her headaches.

If she had more than three headaches a month, you could discuss prophylactic regimens, and recommend magnesium oxide and riboflavin. If the frequency of headaches were higher than three per month, you could recommend topiramate prophylaxis and prescribe a triptan for abortive use.

Headache clinical case #2

A 29-year-old woman presents with frequent stress headaches, beginning three months ago. She has been treated for anxiety in the past.

She states that she has had headaches since her teens and with a recent job change, they have become more frequent, occurring two to three times per week. The headaches have also been increasing in both intensity and frequency. She reports the pain severity as 5 out of 10. The headaches are bilateral, with a steady aching pain. They last all day and will sometimes linger into the next day.

She does not have light sensitivity, nor does she experience nausea.

She has been able to continue with her work and activities.

Location: bilateral

Pain characteristics: aching and steady (non-throbbing)

Associated complaints: none (it is not worse with activity and no photophobia or nausea occur)

This patient experiences tension-type headaches.

If her examination is otherwise normal, do not ask for further testing unless she fails treatment or there are further changes.

To follow this closely, you could ask her to download a headache diary app or to keep a paper diary.

Her headache frequency warrants consideration for a prophylactic regimen. You could suggest an antidepressant for this purpose—perhaps a tricyclic or selective serotonin reuptake inhibitor (SSRI)—to aid in addressing her anxiety. For symptomatic pain, you would prescribe a nonsteroidal anti-inflammatory drug (NSAID).

Headache clinical case #3

A 52-year-old man presents with a six-year history of recurrent headaches. Each fall, he experiences nearly daily headaches that occur around two o’clock each morning. These awaken him with severe pain, and last from 30 to 50 minutes. Occasionally he will experience more than one event. These bouts of headache will occur for two to four weeks, and then he is symptom-free for months at a time.

There is reddening and conjunctival injection (hyperemia) of his left eye vessels, tearing of that eye, and left-sided nasal congestion. He paces up and down the hall of his home during an event.

Location: unilateral supraorbital

Pain characteristics: severe

Duration: short

Frequency: daily (more than once per day)

Course: In this case, the temporal pattern of headache occurrence is key to diagnosis

Associated complaints: trigeminal autonomic symptoms, such as nasal congestion and conjunctival injection

In addition, he becomes restless with the severe pain.

This patient is experiencing cluster headaches, the most common type of trigeminal autonomic cephalgia.

If his examination is otherwise normal, his long history suggests that he does not need imaging.

If he did not have trigeminal cephalic changes, a blood test with erythrocyte sedimentation rate (ESR) would be warranted to evaluate this unilateral headache.

Historical exploration for other features of temporal arteritis is appropriate.

You could prescribe a tapering course of prednisone and sumatriptan injections for the exacerbation of headache. Alternatively, 100% oxygen could be used in place of the triptan injection. A prophylactic—before his seasonal clusters begin—is another strategy that you could discuss with him.

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Recommended reading.

• Blumenfeld, AM. 2018. Botox for chronic migraine: Tips and tricks.  Practical Neurology .  17 : 27–36.  https://practicalneurology.com
• Halker Singh, RB, Starling, AJ, and VanderPluym, J. 2019. Migraine acute therapies.  Practical Neurology .  17 : 63–67.  https://practicalneurology.com
• Krel, R and Mathew, PG. 2019. Procedural treatments for headache disorders.  Practical Neurology .  17 : 76–79. https://practicalneurology.com
• Mauskop, A. 2012. Nonmedication, alternative, and complementary treatments for migraine.  Continuum (Minneap Minn) .  18 : 796–806.  PMID: 22868542
• Motwani, M and Kuruvilla, D. 2019. Behavioral and integrative therapies for headache.  Practical Neurology .  17 : 85–89.  https://practicalneurology.com
• Natekar, A, Malya, S, Yuan, H, et al. 2019. Migraine preventative therapies in development.  Practical Neurology .  17 : 54–57.  https://practicalneurology.com
• Parikh, SK and Silberstein, SD. 2018. Calcitonin gene-related peptide monoclonal antibodies.  Practical Neurology .  Feb : 20–22.  https://practicalneurology.com
• Rizzoli, PB. 2012. Acute and preventative treatment of migraine.  Continuum (Minneap Minn) .  18 : 764–782.  PMID: 22868540
• Tepper, SJ and Tepper, DE. 2018. Neuromodulation and headache.  Practical Neurology .  17 : 42–45. https://practicalneurology.com

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Headache case study with questions and answers

Headache example case study: How to investigate and treat headache

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