(Disclaimer: This article is for scientific use only, and the relevant information in the following content has been processed to protect patient privacy)
Abstract: The patient, a 27-year-old young man, presented 3 days ago with a severe headache and intense pain, manifested by continuous head distension and tension in the muscles of the head and neck. He took pain medication with poor effect and rushed to the hospital. No significant abnormality was seen in the cranial CT examination. Combining the patient’s symptoms and signs with his past medical history, he was considered to have neuropathic headache, and was given symptomatic medication.
Basic information】Male, 27 years old
Disease Type】Nervous headache
Hospital】Shandong Provincial Third Hospital
Date of consultation】December 2021
Treatment plan】Medication (carbamazepine tablets, pethidine hydrochloride tablets, baclofen tablets)
Treatment period】Outpatient treatment, follow-up after 1 month
Treatment effect】Stable condition, no special discomfort
I. Initial consultation
The patient was irritable when he came to the clinic. He reported that he had a severe headache 3 days ago due to recent work stress, and the headache was progressively worsening. His body temperature was normal and he had no other symptoms. Because of the headache and poor rest at night, he took oral pain medication such as ibuprofen extended-release capsules on his own, but the effect was not good, so he came to the clinic. After understanding the patient’s past history of no specific diseases, neurological examination: no obvious positive signs; outpatient perfect cranial CT examination, no obvious abnormalities were seen. Outpatient diagnosis: neuropathic headache. The patient was advised to take medication and to follow up regularly. The patient expressed understanding and cooperated with the treatment.
(Cranio-cerebral CT)
II. Treatment history
The patient’s headache was severe, mainly manifested as dull pain and distension, accompanied by a feeling of numbness and tightness of the scalp. Combining the patient’s clinical symptoms and past medical history, the diagnosis of neuropathic headache was considered, and the patient was given carbamazepine tablets, pethidine hydrochloride tablets and baclofen tablets for antispasmodic and analgesic symptomatic treatment. The patient was advised that neuropathic headache is usually associated with mental tension, anxiety, emotional excitement, staying up late, exertion, and exposure to wind and cold, etc. Therefore, it is necessary to pay attention to the reasonable release of emotions and pay more attention to rest in life.
III. Treatment effect
The patient’s headache symptoms were relieved on the second day and significantly relieved on the fifth day after symptomatic treatment with carbamazepine tablets, pethidine hydrochloride tablets and baclofen tablets. 1 week later, the patient reported that the headache symptoms were relieved and no other discomfort occurred. 1 month later, the patient was seen again in the outpatient clinic and had no special discomfort and no recurrence of headache, so the patient was advised to develop good living habits to avoid recurrence or aggravation of headache. The patient was very satisfied with the treatment effect.
IV. Notes
We are glad that the patient’s headache was relieved after treatment, but because of the severity of the headache and the tension in the head and neck muscles, muscle relaxing drugs such as baclofen tablets were given to the patient, and the headache should be closely monitored for reduction during treatment. Patients should also monitor their blood pressure and the presence of symptoms such as unconsciousness, nausea and vomiting. If these symptoms occur, they should be differentiated from encephalitis and intracerebrospinal fluid examination should be completed. During the medication period, patients should quit smoking and alcohol, avoid staying up late and straining, maintain emotional stability, take more rest, reduce mental work, and their diet should be light, drink more water, and avoid spicy and stimulating, oily food, which will help the disease to improve and recover.
V. Personal insight
Nowadays, young people work under great pressure and have more mental work, and there are more patients with headaches of varying severity. If headaches persist and cannot be relieved, you should actively go to the hospital to improve cranial MRI, EEG and other related examinations to exclude intracerebral lesions. Doctors should be cautious in treating patients with headaches to avoid missing diagnoses, such as brain tumors, cerebral hemangiomas, and encephalitis. Although work is important, physical health is also important. Patients should pay attention to adjust their habits of life and rest, so that the two-pronged approach can not only get a healthy body, but also help to complete work better. In this case, the patient had frequent headache attacks and heavy symptoms due to his busy work schedule, and the headache did not reappear after he was advised to adjust his lifestyle habits.