Migraine Without Aura
Clinical Presentation and Assessment
The patient is a 19-year-old female presenting with recurrent headaches. She describes sharp, throbbing pain beginning in the right temple or behind the right eye, spreading across the scalp. The headaches occur once or twice a month, lasting up to two days, and are associated with severe nausea, photophobia, and worsening with noise or movement. Relief comes only through rest in a dark, quiet room.
Importantly, her mother has a history of migraines, suggesting a possible hereditary link. She denies alcohol, tobacco, or illicit drug use and remains up to date on preventive care. Vital signs remain stable and within normal limits.
Diagnosis and Management Plan
The clinical features are highly consistent with migraine without aura. The location, pulsating quality, duration, nausea, and sensitivity to light all support this diagnosis. Over-the-counter analgesics provide insufficient relief, suggesting a need for preventive counseling and prescription options.
Education about maintaining hydration, consistent sleep, and regular meals is critical. For acute treatment, prescribing triptans may be appropriate to address migraine attacks effectively.
Tracking frequency, severity, and response to therapy with a headache diary will guide long-term management.
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Migraine Without Aura
Clinical Presentation and Assessment
The patient is a 19-year-old female presenting with recurrent headaches. She describes sharp, throbbing pain beginning in the right temple or behind the right eye, spreading across the scalp. The headaches occur once or twice a month, lasting up to two days, and are associated with severe nausea, photophobia, and worsening with noise or movement. Relief comes only through rest in a dark, quiet room.
Importantly, her mother has a history of migraines, suggesting a possible hereditary link. She denies alcohol, tobacco, or illicit drug use and remains up to date on preventive care. Vital signs remain stable and within normal limits.
Diagnosis and Management Plan
The clinical features are highly consistent with migraine without aura. The location, pulsating quality, duration, nausea, and sensitivity to light all support this diagnosis. Over-the-counter analgesics provide insufficient relief, suggesting a need for preventive counseling and prescription options.
Education about maintaining hydration, consistent sleep, and regular meals is critical. For acute treatment, prescribing triptans may be appropriate to address migraine attacks effectively.
Tracking frequency, severity, and response to therapy with a headache diary will guide long-term management.
