Code Status case · Beginner · Premium
Headache in a 29-year-old woman
“I have a headache. It started this morning and kept getting worse.”
“Headache since about seven this morning, gradually worsening through the day. She vomited once in the waiting room. Pain is eight out of ten. Vitals are normal. She's asking for the lights off.”
Your challenge
Sofia's headache started at seven this morning and has climbed all day. She has vomited once, her pain is eight out of ten, and she wants the lights off. A migraine, bleeding around the brain, a clot in the brain's veins, an infection or a tumor can all look like this at first. The skill is asking the questions that find the dangerous ones, and knowing when you have asked enough.
After the case, Attending’s Notes explains the decisions that mattered, backed by 10 sources.
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Spoiler: the diagnosis and what this case teaches
Diagnosis
Migraine Without Aura
Lesson 1
Exclude the Dangerous Headache First
Name the pattern, then ask what would make it dangerous.
- Recurrent throbbing pain with nausea fits migraine
- Work up sudden peak pain or other red flags
- Pain intensity alone does not decide imaging
- Sudden peak headache needs a bleeding workup
Lesson 2
Treat Migraine With Proven Nonopioid Medicines
Choose a treatment that relieves headache and addresses nausea when present.
- Use prochlorperazine or metoclopramide IV
- Do not add ketorolac to another NSAID
- Consider subcutaneous sumatriptan 6 mg if eligible
- Give fluids for dehydration and avoid routine opioids
Lesson 3
Reassess Before Adding Another Migraine Drug
A new finding may require a different diagnosis and workup.
- Reassess and repeat the neurologic examination
- Check new red flags before adding another drug
- Choose another proven migraine drug not yet given
- Dexamethasone can reduce early recurrence
Lesson 4
Safe Discharge Does Not Require Zero Pain
Control, safety, and a plan decide discharge. The pain score alone does not.
- Home if function improves and exam reassures
- Give a rescue plan and arrange follow-up
- Observe or admit if symptoms stay disabling
- Repeated migraine visits call for prevention, not opioids
In the app, every line above opens into the detail behind it: doses, pitfalls and the evidence, with 10 sources linked to the originals.
Sofia is a fictional patient. Code Status is for training only and is not intended for real-world patient care, diagnosis, treatment, or clinical decision-making.