61-Year-Old With Irritability, Headaches, and Weight Loss

Heidi Moawad, MD


November 13, 2023

Editor's Note:
The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a future Case Challenge, please contact us.


A 61-year-old woman has had sleep disruption, irritability, and headaches for the past 3 weeks. She received a diagnosis of chronic tension headache about 10 years ago. The headaches she has been experiencing recently, however, are much more painful than her usual headaches. She describes a sharp pain with an electric-shock sensation, in contrast to the dull ache of her tension headaches. The pain has been relentless since it started and has not responded to ibuprofen or acetaminophen, which are typically effective.

Additionally, for approximately the past 10 years, she has experienced joint pain and muscle aches after physical exertion. Her physician attributes these symptoms to obesity. She says that she is unable to exercise because of the pain and that this problem has created a cycle of pain and obesity. She has also had eczema since childhood, and the condition can flare up when she is tired or is under stress.

The patient explains that she has been under an unusual amount of stress lately, owing to accounting issues in the business she runs with her husband, and she wonders whether her recent symptoms could be a reaction to this stress. She has also lost 10 lb (4.5 kg) over the past few weeks because she has been unable to eat as a result of her stress. She explains that the pain, hunger, and lack of sleep have made her irritable to the point of snapping at anyone who tries to talk to her. On further questioning, she says that the headaches worsen when she brushes her teeth or tries to eat.


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