Patient
47-year-old female, follow-up for persistent headaches
Subjective
Reports three weeks of intermittent frontal headaches, usually late afternoon and worse after screen-heavy workdays. Pain is pressure-like, 5/10, without vomiting, focal weakness, visual loss, or aura. Ibuprofen helps partially. Sleeping 6 hours on work nights. No recent head injury. Denies pregnancy possibility.
Objective
BP 128/78, HR 72, afebrile. Alert and oriented. Cranial nerves II–XII intact. Pupils equal and reactive. Extraocular movements full. No pronator drift. Strength and sensation symmetric. Fundoscopic examination without papilledema. Mild bilateral trapezius tenderness.
Assessment
- Episodic tension-type headache, without red-flag features.
- Contributing sleep restriction and prolonged screen exposure.
Plan
- Keep a headache and trigger log for four weeks.
- Increase sleep opportunity toward 7–8 hours and take regular screen breaks.
- Trial naproxen 250 mg with food as needed, not more than 3 days per week.
- Return sooner for sudden severe headache, persistent vomiting, new neurologic symptoms, fever, or visual change.
- Follow up in four weeks if symptoms have not improved.