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Abstract: A 21-year-old female patient came to the clinic. After understanding that the patient had recently been preparing for the examination and was under high mental stress, studying late at night, she had recently experienced frequent headaches, and their frequency was gradually increasing. Based on the patient’s symptoms, it was considered that it might be a tension headache related to the patient’s high mental stress and insufficient rest. Therefore, the patient was given medication to relieve the headache symptoms and improve the patient’s tension, as well as to adjust her lifestyle, and eventually the headache symptoms disappeared and her quality of life improved.
[Basic information] Female, 21 years old
Type of disease】Tension headache
Hospital】Beijing Tiantan Hospital
Date of Consultation】August 2021
Treatment plan】Oral medication (ketoprofen extended-release capsule, flunarizine hydrochloride capsule, Xieyu tranquilizer capsule, glutamate tablet) + lifestyle adjustment
Treatment period】2 weeks
Treatment effect] Headache symptoms disappeared, quality of life improved
I. Initial consultation
A 21-year-old female patient came to the clinic. After understanding that the patient had recently been preparing for the examinations and was under high mental stress, she had been studying late at night and had been experiencing headaches frequently recently. When the headache symptoms are severe, the patient may even have dizziness, dry eyes, astringent eyes, and dry vomiting, but they can be relieved after rest. In order to exclude the possibility of intracranial lesions, the patient was given a cranial CT examination, which showed no abnormalities in the morphology and density of the brain tissue in each department. Therefore, according to the patient’s symptoms, the diagnosis was tension headache, which might be related to the patient’s high mental stress and insufficient rest.
II. Treatment history
After the diagnosis was confirmed, the patient was given the following treatments.
1. Drug treatment: Since the patient’s headache attacks were more frequent and seriously affected normal study life, the patient was given non-steroidal anti-inflammatory drugs for pain relief, i.e. oral ketoprofen extended-release capsules and flunarizine hydrochloride capsules to improve cerebral microcirculation and neuronal metabolism, inhibit cerebral vascular spasm, improve blood supply to the brain, and relieve headache. At the same time, give Chinese patent medicines to relieve liver and depression and calm the mind, such as Xie Yu An Shen Capsules, to relieve patients’ symptoms of anxiety, tension and insomnia, as well as using glutamate tablets to sedate and help sleep.
2.Adjustment of lifestyle: Patients are instructed to pay attention to sleep, work and rest reasonably, study during the day and sleep at night to improve sleep status and prevent headache attacks. Take appropriate sports, you can choose walking, swimming, etc., but the exercise should be moderate and not too fatigue.
III. Treatment effect
After 1 week of medication treatment, the patient’s headache improved significantly, so she stopped using ketoprofen extended-release capsule, and flunarizine hydrochloride capsule. After 14 days of medication follow-up, the patient’s headache appeared less frequently and her mood improved, so she stopped the antidepressant capsule and continued to take glutamate tablets, and insisted on lifestyle adjustment. After the lifestyle adjustment and medication, the patient’s bad emotions such as tension and anxiety decreased, no more symptoms of dizziness, dullness, nausea and vomiting, sleep was improved, and finally the headache was completely relieved and the quality of life was improved compared with that before treatment.
IV. Notes
We are glad that the patient’s symptoms have improved after treatment. To prevent the reappearance of symptoms, the patient needs to pay attention to the following points.
1. In life, patients should develop good habits of work and rest, go to bed early and wake up early, and avoid staying up late. At the same time, you can exercise appropriately according to your own situation, but pay attention to the prohibition of strenuous exercise before going to bed, so as not to affect sleep. In addition, patients can do outdoor activities in their leisure time to relieve stress and make their emotions stable.
2. In terms of diet, pay attention to a light diet and eat more vegetables and fruits rich in vitamins to increase the immunity of the body. Avoid eating spicy, stimulating, and greasy food to avoid indigestion affect sleep, and avoid eating before going to sleep, as well as drinking coffee, wine and other stimulating beverages.
V. Personal insight
Tension headache is more common in clinical practice and is often related to various factors, especially rest and emotional factors. In this case, the patient had tension headache due to excessive stress in preparing for the examination and irregular sleep. After lifestyle improvement, supplemental rest, and appropriate medication, her headache symptoms gradually improved.
Patients with tension headaches can have their headaches relieved by adjusting their lifestyle, maintaining a regular routine, avoiding late nights, and exercising appropriately. If the symptoms are more serious, medication, such as non-steroidal anti-inflammatory drugs, as well as sedative and tranquilizing Chinese medicine, can be used to achieve better results.