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Yolanda Jones is a 40-year-old female presenting with complaint of headache. Yolanda reports her headache is 5/10 in back of her head associated with some neck discomfort and it began yesterday. The pain feels like a vice wrapping around her head at times. She has not had any recent illness, fever, cough, cold symptoms, or nausea. She denies any seasonal allergies. Yolanda works as an attorney downtown representing business firms. She has been traveling a lot lately and finds she is drinking 3-4 cups of coffee a day and not drinking much water when she travels. She has been participating in exercise classes at the gym and likes the cycling class the best. She is not a smoker and drinks a glass of wine 1-2 times a month with meals. She had a car accident 10 years ago and does have some arthritis in her neck and shoulders, but never broke any bones or major injuries with the accident. Yolanda reports she has been taking Tylenol every day for headaches sometimes she takes it just in case she is going to have a headache to prevent it. She is still getting menstrual cycles LMP 1 week ago. Yolanda is sexually active and is currently using a Mirena IUD for contraception. She feels like she has gained some weight, about 5 pounds in the last 6 months. She wears contacts for distant vision and has not had noticed changes in her vision. Her mother has a history of migraine headaches and she wonders if she needs to start taking medication for migraine headaches. Yolanda denies depression, but does have some trouble sleeping, often getting only 5 hours at night. What are some of your differential diagnoses in this case? What other information would you seek from this patient? What tests or diagnostic tools would you consider in this case, if any?
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