TB, 20-year-old, Male, Caucasian
CC Intermittent headaches.
HPI: T.B. is a 20-year-old Caucasian male who presents with intermittent, diffuse headaches. His headaches have been occurring every week or so since Spring, 2018. These headaches last for 2 to 3 days and occur over entire head but is worse above the eyes and radiates the nose, cheekbones, and jaw. The pain is described as a pressure that is intense above the eyes. There are no associated signs or symptoms, other than mild relief when enters a dark room. T.B has not discovered a condition that makes headaches occur or worsen. Currently, the pain is rated as 7/10 pain scale.
Current Medications: Intermittent Acetaminophen Extra Strength 2 several times a day with headaches
Allergies: None is known to date.
PMHx: Reports has received all recommended immunizations and last tetanus is in 2016. Appendectomy at age 15.
Soc Hx: Patient is a part-time student at local community college and works part-time as a Barista. He denies tobacco or recreational drug use, no alcohol use since 2017 in high school. He reports recently beginning to vape. He lives with a roommate in an apartment and reports has been more active as walks 3 miles daily to work and school.
Fam Hx: Mother is living and in good health. Father has not been in the patient’s life since infancy. Sister was diagnosed with epilepsy several years ago. Patient reports no known family history of cancer or neurological issues
GENERAL: Patient reports no weight loss or fever
HEENT: Eyes: Patient reports no visual changes
Ears, Nose, Throat: Patient reports no hearing loss, congestion, runny nose or sore throat.
SKIN: Patient reports no rash or itching.
CARDIOVASCULAR: Patient reports no chest pain, chest pressure or chest discomfort.
RESPIRATORY: Patient reports no shortness of breath, cough or sputum.
NEUROLOGICAL: Patient reports no dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities.
LYMPHATICS: Patient denies knowledge of enlarged nodes. No history of splenectomy.
PSYCHIATRIC: No history of depression or anxiety reported.
ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia reported.
ALLERGIES: No history of asthma, hives, eczema or rhinitis reported.
Diagnostic results: MRI should be considered to determine if there is a demyelinating disease or tumor triggering pain. There is no actual diagnostic tool for trigeminal neuralgia temporal, but other causes should be ruled out (Ball, Dains, Flynn, Solomon, & Stewart, 2015).
CT Scan could be ordered if felt to be sinusitis that does not respond to conservative or antibiotic treatment can lead to rare but dangerous sphenoid sinusitis affecting nerves (Velayudhan, Chaudhry, Smoker, Shinder, & Reede, 2017). CT scan is preferred over MRI for sinusitis diagnosis.
A dental referral would be recommended if another diagnosis is ruled out or pain has oral pain or sign of dental inflammation.
Additional questions for the patient would be
Do you associate the pain with a specific event or timing?
How long have you experienced this pain?
Is the pain increasing, decreasing, or staying the same?
What makes the pain better?
Have you experienced similar pain before?
Do you have pain with chewing?
Do you grind your teeth?
Do you have nasal or postnasal drainage?
Do you have a fever?
A. Headache with facial pain
Trigeminal neuralgia temporal: The trigeminal nerve sends impulses to the upper, middle, and lower portions of the face. In this case, more than one nerve branch may be irritated and sending signals of pain to the upper head and the middle including the nose, cheekbones, and jaw. It is possible for this pain to be bilateral (National Institute of Neurological Disorders and Stroke, n.d). Some possible triggers of trigeminal pressure might be pressure from blood vessels or rarely a tumor. Another trigger could be demyelination, such as Multiple Sclerosis (MS). Ball, Dains, Flynn, Solomon, & Stewart (2015) report this condition occurs in older patients. An MRI should be considered to determine if another diagnosis such as MS is triggering the pain.
Headache due to reaction from electric cigarette/Vaping. Cai & Wang (2017) shared the strong evidence of neurological effects from e-cigarette solvents and flavor additives. The substances produced from vaping are acrolein, glycerol, propylene oxide, ethyl, ethyl matol, and methol which are toxic and related to neurological issues. Li, Zhan, Wang, Leischow, and Zeng (2016) reported severe headaches occurred after e-cigarette use due to high nicotine and propylene glycol. Fruit flavors also contributed
Sinusitis: The frontal sinuses lie above the eyes which could contribute to the primary site of pain. The maxillary sinus could be inflamed causing the upper jaw, teeth, nose and cheek pain. One concern is sinusitis typically has postnasal discharge (Ball, Dains, Flynn, Solomon, & Stewart, 2015)
Tension-type headache (TTH): A primary symptom of TTH is a hatband pain distribution (Ball, Dains, Flynn, Solomon, Stewart (2015). Although rare, Wagner and Moreira Filho (2018) studied a TTH combined with temporomandibular junction sleep bruxism occurs during periods of anxiety. This combined scenario could reflect the upper eye and jaw, cheek pain.
Dental Caries or Malocclusion: Ball, Dains, Flynn, Solomon, and Stewart (2015) reports dental disease is a primary source of pain in the jaw, but also could cause pain at top of the head. In our patient’s case, the pain starts below the forehead and radiates lower making this diagnosis less likely.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.
Hua Cai, & Chen Wang. (2017). Graphical review: The redox dark side of e-cigarettes; exposure to oxidants and public health concerns. Redox Biology 3(C) 402-406 https://doi-org.ezp.waldenulibrary.org/10.1016/j.redox.2017.05.013
Li, Q., Zhan, Y., Wang, L., Leischow, S. J., & Zeng, D. D. (2016). Analysis of symptoms and their potential associations with e-liquids’ components: a social media study. BMC public health, 16, 674. doi:10.1186/s12889-016-3326-0
National Institute of Neurological Disorders and Stroke. (n.d). Trigeminal neuralgia fact sheet. Retrieved from https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Trigeminal-Neuralgia-Fact-Sheet
Velayudhan, V., Chaudhry, Z. A., Smoker, W. R. K., Shinder, R., & Reede, D. L. (2017). Imaging of intracranial and orbital complications of sinusitis and atypical sinus infection: What the radiologist needs to know. Current Problems in Diagnostic Radiology, 46(6), 441–451. https://doi-org.ezp.waldenulibrary.org/10.1067/j.cpradiol.2017.01.006
Wagner, B. de A., & Moreira Filho, P. F. (2018). Painful temporomandibular disorder, sleep bruxism, anxiety symptoms and subjective sleep quality among military firefighters with frequent episodic tension-type headache. Arquivos De Neuro-Psiquiatria, 76(6), 387–392. https://doi-org.ezp.waldenulibrary.org/10.1590/0004-282X20180043