[22F] Experiencing headache, confusion, and vertigo with additional symptoms

Patient Description

A 22-year-old female presents with a 2-hour history of a gradually worsening aching headache rated 7/10 in intensity, associated with confusion and vertigo. The patient describes the vertigo as a sensation of being off balance and dizzy, rating it 5/10 in severity. She also reports sharp eye pain rated 3/10, blurry vision, a sore throat, and a runny nose. The headache is exacerbated by work, stress, and loud noise, with sleep providing some relief. The patient has a history of anxiety and depression, diagnosed 3 years ago, and is currently taking Clexia 40 mg at night, gabapentin 600 mg at night, and propranolol 10 mg in the morning and at night. She has experienced side effects from Clexia, including anger and frustration. There is a family history of migraines. No recent injuries, nausea, vomiting, neck stiffness, fever, or new neurological symptoms have been reported. The patient denies any recreational drug use and has no known allergies or adverse reactions to medications.

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Arora's Assessment

What might be happening

Based on the information you've provided, there are several possible explanations for your symptoms:

  • Migraine: This is a type of headache characterized by severe, throbbing pain, often on one side of the head. It can be accompanied by other symptoms such as sensitivity to light and sound, dizziness, and blurred vision. Your history of anxiety and depression, as well as a family history of migraines, could increase your risk of experiencing migraines.

    • Treatment typically involves pain-relieving medications and preventive medications. Lifestyle changes, such as stress management and regular sleep, can also help.

  • Viral infection: Your symptoms of a sore throat and runny nose suggest a possible viral infection, such as the common cold or flu. The headache and eye pain could be related to this infection.

    • Treatment usually involves rest, hydration, and over-the-counter medications to relieve symptoms.

  • Side effects of medication: Some of your symptoms, particularly the confusion and dizziness, could be side effects of the medications you're taking. Clexia (which I believe may be a misspelling of Lexapro, a common antidepressant), gabapentin, and propranolol can all potentially cause these side effects.

    • If you suspect your symptoms are related to your medication, it's important to discuss this with your doctor. Do not stop taking your medication without consulting your doctor first.

What you can do

  1. Rest and hydrate: If you have a viral infection, rest and hydration are key. Over-the-counter medications can also help relieve symptoms.
  2. Monitor your symptoms: Keep track of when your symptoms occur, their severity, and any potential triggers. This can help you and your healthcare provider identify patterns and potential causes.
  3. Consult your doctor: Given the severity and sudden onset of your symptoms, it's important to consult a healthcare provider. They can evaluate your symptoms, consider your medical history, and possibly adjust your medication if necessary.

What you should look out for

Seek immediate medical attention if:

  • Your symptoms worsen or do not improve within a few days
  • You experience severe headache or neck stiffness
  • You have difficulty speaking or understanding speech
  • You have weakness or numbness on one side of your body
  • You have a high fever or severe throat pain

Remember, this advice is intended to be general in nature, and specific causes may not apply to your situation. Always consult with a healthcare provider for appropriate examination, diagnosis, and treatment.

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9 mo ago

People Also Ask

What are the common symptoms of a migraine and how can they be managed?

Common symptoms of a migraine include severe, throbbing headache, often on one side of the head, sensitivity to light and sound, nausea, and sometimes visual disturbances. Management typically involves pain-relieving medications, preventive medications, and lifestyle changes such as stress management, regular sleep, and avoiding known triggers.

Can a viral infection cause headaches and eye pain, and what are the typical treatments?

Yes, a viral infection like the common cold or flu can cause headaches and eye pain due to inflammation and congestion. Typical treatments include rest, hydration, and over-the-counter medications to relieve symptoms such as pain and congestion.

What are the potential side effects of medications like Lexapro, gabapentin, and propranolol?

Lexapro (escitalopram), gabapentin, and propranolol can cause side effects such as dizziness, confusion, fatigue, and mood changes. It's important to discuss any concerning side effects with a healthcare provider, as they may need to adjust the medication or dosage.

How can stress and anxiety contribute to headaches and what strategies can help manage them?

Stress and anxiety can contribute to headaches by causing muscle tension and changes in brain chemicals. Strategies to manage them include relaxation techniques, regular exercise, adequate sleep, and sometimes counseling or therapy to address underlying issues.

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