Brooke Johnson: A 30-Year-Old Teacher With Frequent Headaches Involving the Head and Neck

Brooke Johnson

Brooke Johnson is a 30-year-old teacher with the chief complaint of, “My headache medications quit working.” Brooke went on to say that she couldn’t remember the last time that she didn’t have a headache. “Doctor, anymore, I have a headache 24/7. It doesn’t matter how much medication I take, my headaches keep coming back. The headaches make it impossible to concentrate. I’m cranky with everyone, and everyone is driving me crazy. I’m anxious all of the time.”

I asked Brooke how long she’s had headaches and she said, “I’ve had headaches about as long as I can remember.” Brooke said that all of the headache medication she was taking was “eating a hole in my stomach. I take my Fiorinal and Advil, and my headache gets better for a few minutes and then it is back as bad as ever. I take some more, the headache gets better for a few minutes and then it comes right back.” She denied any fever, chills, or neurologic symptoms associated with her headaches.

I asked Brooke to use one finger to point at the spot where it hurt the most, and she pointed to both her temples and then started rubbing her neck. I asked her what the pain was like: an ache, sharp, stabbing, burning? She immediately said, “My entire head just hurts! It just hurts. No throbbing, no stabbing, it just hurts. And my meds don’t work. No matter how many I take! I am really up the creek here. Oh, and don’t let me forget that I need you to refill my Fiorinal.” I asked whether the headache was on both sides or just one side, and she said it was the entire head. I asked Brooke from the time that she knew that she was going to get the headache until the time it was at its worst, was it a period of seconds, minutes, or hours. She said, “Like I told you, I get the headache, I take my headache meds, it gets better for a bit, and then the same headache starts to come back. I take more meds, the headache gets better for a bit, it comes back, and then I take more meds to try and get some relief. I feel like a hamster on a wheel; this is the pits.” I asked Brooke how her sleep was, and she replied, “Who has time to sleep? I’m too busy getting up to take my headache pills. Oh, and before I forget, I need you to refill my Fiorinal.”

On physical examination, Brooke was afebrile. Her respirations were 16 and her pulse was 78 and regular. Her blood pressure was 128/82. There were no cranial abnormalities, and her head, eyes, ears, nose, throat (HEENT) examination was completely normal, as was her fundoscopic examination. Her cervical paraspinous muscles were tender to deep palpation, but no myofascial trigger points were identified. Her cardiopulmonary examination was normal, as was her thyroid. Her abdominal examination revealed no abnormal mass or organomegaly, and there was no rebound tenderness present. There was no costovertebral angle (CVA) tenderness. There was no peripheral edema. A careful neurologic examination of the upper and lower extremities revealed no evidence of weakness, lack of coordination, or peripheral or entrapment neuropathy, and her deep tendon reflexes were normal. There were no pathologic reflexes. Brooke’s mental status exam was within normal limits, but her anxiety was apparent.

Key Clinical Points—What’s Important and What’s Not