A 28-year-old woman, not known to you, presents with headache and requests the product Migraitan that her friend has recommended. She tells you the headache has been present since yesterday and hasn’t responded to the paracetamol she has taken. She is otherwise fit and healthy and has no medical problems

Problem representation

Acute onset headache in a healthy female.

Problem refinement

Acute headache is a symptom of many conditions, either as the main presenting symptom (e.g. migraine) or one of many symptoms (e.g. infections). Based on the problem representation you need to test hypotheses of the most likely causes of her headache. For the patient, the conditions to consider in the first instance would be:

• Tension-type headache
• Migraine
• Sinusitis
• Eye strain.

As tension-type headache causes approximately 90 per cent of all acute headache presentations, it is logical to hypothesise that this will be the cause of her headache. Questions should be targeted to test this hypothesis even though the patient has requested a product specifically for the treatment of migraine.

Continued information gathering

As questions will be targeted to test the working differential diagnosis of tension-type headache, it is important to be familiar with its presentation and understand how this differs to those other conditions that need to be initially ruled out.

Tension-type headache typically presents with pain that is generalised, non-throbbing in nature and tends not to be severe enough to interfere with daily activities. The pain often is described as a tightness or a weight pressing down on the head. Therefore asking about the location, nature and severity of the pain are useful opening questions.

Location of pain: Conditions to eliminate show differing symptom presentation. Migraine is usually one-sided; sinusitis and eye strain exhibit frontal pain. This differs from tension-type headache, which is generally bilateral with pain towards the back of the head.

Nature of pain: Migraine is described as pulsating or throbbing pain. Eye strain and sinusitis tend to show localised aching pain.

Severity of pain: Although pain is subjective, an assessment can be made by getting patients to rate the level of pain on a scale or asking if the pain is debilitating. Migraine and sinusitis can cause severe pain affecting the patient’s ability to function normally. This would not be expected with tension-type headache or eye strain.

Based on the knowledge of how these conditions present, by asking the patient these three questions, you should be able to confirm or refute a differen- tial diagnosis of tension-type headache.

Problem refinement

When asking these questions you find out the pain of her headache is pulsating, mainly on her left side and she rates the pain as six out of 10. This description does not support the differential diagnosis of tension-type headache and fits more closely with migraine. You therefore should ask further questions to now consider migraine as the cause. Pertinent questions would centre on associated symptoms and personal history.

Associated symptoms: Almost all migraine sufferers experience nausea. A small proportion will also have visual or neurological symptoms prior to the headache. This would not be experienced in any of the other headache conditions you would first consider as possibilities.

Sinusitis is a complication from an upper respiratory tract infection and consequently the patient should have a recent history of cough/cold symptoms. Further symptoms of dislike to lights and noise would support migraine as the diagnosis.

Personal history: If this is not a patient’s first migraine attack, they will normally have a history of recurrent and episodic attacks of headache.
This would be unusual in eye strain and sinusitis but repeated headaches caused by tension-type headache can occur. The patient tells you she is feeling sick but has no other symptoms and has not had this type of headache before. Based on this it appears that migraine is the most likely diagnosis.

Management and safety netting

The patient has taken paracetamol, which appears to have been ineffective, and so her request for Migraitan (sumatriptan 50mg) appears to be an appropriate choice, although it is most effective taken at the onset of symptoms. Sumatriptan

is, however, subject to greater OTC restrictions compared to that for POM supply (e.g. age, history of cardiovascular disease and seizures) and in this instance the sale should not be made as there needs to be an established pattern of migraine.

In this case the patient could be given ibuprofen at a dose of 400mg three times a day as this is superior to the 200mg dose. If symptoms do not disappear within 48 hours, the patient should

be told to see a doctor for re-evaluation of her symptoms as migraine attacks do not normally last more than 72 hours.