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A 30-year-old female patient is a cyclist who experienced a fall from her bike two weeks ago while not wearing a helmet. She reports hitting her head on a grass hill, but did not have lacerations or lose consciousness. Since then, she has had daily headaches self-described as a 7/10 pain rating. She did visit the ER the day of the fall, complaining of head, neck and hip pain. X-rays were negative for fractures, and she was negative for concussion. She was given acetaminophen for the pain and referred to a headache specialist, whom she did not see because her insurance did not cover the referral visit.

Two weeks after the fall, the patient reported to the ER with a severe migraine. Since the accident, she has had frequent headaches up to five times per week, with pressure in the temple and behind the eye. She tells the doctor she has been taking higher than recommended dosage of acetaminophen because the headaches are so intense, and she has increased her caffeine intake to counteract the fatigue. Her headaches are worse on days she works as a waitress in a busy restaurant, with neck pain and fatigue. At work, going into a dark closet with eyes closed has somewhat alleviated the pain. The patient also reports having intermittent migraines for several years (attributed to allergies).

Chronic use of acetaminophen is a well-known trigger for rebound headaches that manifest like tension headaches. Excessive caffeine intake is also a headache trigger. The patient reported fatigue, and sleep is an often overlooked part of a headache evaluation. The recent bike accident may have resulted in mild traumatic brain injury (TBI) that was not initially diagnosed, because hallmark signs of TBI include headaches, fatigue and light sensitivity. The ER attending physician concluded with the original plan of action which was for the patient to be evaluated by a neurologist who specializes in headaches.

Question: Do you think the patient's headaches were more attributed to the fall or to her history of migraine? Do you conclude with the ER physician's plan of action?

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