headache diagnosis Watch

medicneedshelp
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Hello,

A 22yr male presents with headaches and neck pain for 4 months. These headaches are: bilateral, continous (headaches every day, all day for 4 months), characterised by a dull ache/"heaviness" with variable severity throughout the day (4-8/10).
Mild relief obtained from neurofen, paracetamol not effective. Amitriptylline was prescribed for a couple weeks which reduced severity (4/10) but did not totally resolve.

HPC: gradual onset accompanied by blurred vision. Optometrists found signs of an acute eye infection, new astigmatism (both eyes) and signs of corneal damage. The cause was uncertain but most likely due to usage of contact lenses for 12+ hrs/day (soft lenses). Ptx stopped wearing contact lenses and after a month there were signs of improvement to the eyes. After 10w the astigmatism had gone completely in 1 eye & was almost totally gone from the other. The corneal damage had repaired. Despite the resolution to the eye, headaches remained throughout entire period of time and continue into (now into the 17th week).

PMH: nil PSH: nil Allergies: nil known
DH: no previous to incident; has completed 1 course of amitriptylline, prn neurofen & paracetamol
SH: non-smoker, social drinker

Tests: MRI (clear), optical tests (as mentioned in HPC)
Bloods (CRP, ESR, WBC, FBC, BM, LFT, U&E, GFR; taken at 7w): all within normal range except:
RBC (5.37 x 10^12 /l) [normal range: 4.3-5.3] &
basophil (0.01 x 10^9/l) [normal range: 0.02-0.5]

For me it doesn't seem to fit the pattern for any headaches im aware of (may chronic tension) Any ideas? Very much appreciated.

thanks
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medicneedshelp
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any other forums where dr/medics may be able to help will be great also thanks
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Ciaran88
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That's pretty odd.. has he a history of regular (ie. daily) pain relief? Could be rebound.
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j00ni
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Quite a few differentials:

Chronic tension-type headache (probably most common - suggested from Hx)
Medication overuse headache (also common - suggested from Hx)
Daily Persistent headache (possibly fits best w/ symptoms, but diagnosis of exclusion)
Chronic Carbon Monoxide poisoning (needs to be excluded biochemically)
Chronic cluster headache (rare, and usually unilateral/retrobulbar)
Ictal headache (pretty rare in the absence of other seizure symptoms, excluded w/ EEG)
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Ciaran88
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Doesn't sound like a cluster headache at all; too long in duration, daily and non-characteristic

Would an ictal headache, even if you include it despite no supporting Hx, really be persistant and daily?
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Wangers
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scan to include/exclude malignancy, also, consider pseudotumour. I did think giant cell arteritis, but the inflammatory markers are against it...
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Ciaran88
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(Original post by Wangers)
I did think giant cell arteritis, but the inflammatory markers are against it...
Plus would be pretty insane in a 22 year old, but google tells me there was once a case in a 17 year old :eek:
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Jamie
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whatever it is is beyond the level of anyone in this fora.

Some people set really ****e questions in exams/pbl.
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edcourageous
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(Original post by Jamie)
whatever it is is beyond the level of anyone in this fora.

Some people set really ****e questions in exams/pbl.
Given that it's a 22 yr old male, and sounds quite unlike an exam qu, I reckon it could be OP/friend of OP
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Jamie
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(Original post by Wangers)
scan to include/exclude malignancy, also, consider pseudotumour. I did think giant cell arteritis, but the inflammatory markers are against it...
IF his ESR was 120 it would still not be GCA.

Worldwide less than a dozen documented cases of GCA below 50 years old.

Remember that
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Egypt
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(Original post by Jamie)
IF his ESR was 120 it would still not be GCA.

Worldwide less than a dozen documented cases of GCA below 50 years old.

Remember that
My mother in law was diagnosed aged 50 and 3 months by biposy after having symptoms for 18 months but was only investigated after she turned 50. I knew she was special but not that special :eek:
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Renal
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(Original post by Egypt)
My mother in law was diagnosed aged 50 and 3 months by biposy after having symptoms for 18 months but was only investigated after she turned 50. I knew she was special but not that special :eek:
Have you even set a date?
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Egypt
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(Original post by Renal)
Have you even set a date?
Nope! We've decided on a country though which is a good start!
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medicneedshelp
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(Original post by edcourageous)
Given that it's a 22 yr old male, and sounds quite unlike an exam qu, I reckon it could be OP/friend of OP
You're right, this isn't an exam q, it is a real life case (my relative who has given me permission to post here - he is fed up with the headaches as you can imagine)

Unfortunatley the dr appear bamboozled also which means he is suffering 24hrs/day 7d a week which as medics you can imagine is terrible so any help will be really helpful.

Anyone know any websites which might have headache specialists i can ask?

Also thank you everyone for your input, and additional ideas will be much appreciated.
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Jamie
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(Original post by medicneedshelp)
You're right, this isn't an exam q, it is a real life case (my relative who has given me permission to post here - he is fed up with the headaches as you can imagine)

Unfortunatley the dr appear bamboozled also which means he is suffering 24hrs/day 7d a week which as medics you can imagine is terrible so any help will be really helpful.

Anyone know any websites which might have headache specialists i can ask?

Also thank you everyone for your input, and additional ideas will be much appreciated.
only one more set of tests I can think of.
Antiphospholipid antibodies and lupus anticoagulant.

Study by Prof Hughes (of Hughes Syndrome fame) found that something like 10-15% of chronic migraine disorders are actually APS sufferers whose symptoms improve with anticoagulation.
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