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A 29-year-old female presents to the emergency room complaining of a migraine with fatigue, neck pain and light sensitivity. However, two weeks prior, she had a bicycle accident. She was not wearing a helmet when she crashed on the grass. She has had daily painful headaches since, and has been taking high doses of acetaminophen for the pain.

She tells the ER nurse that she had no head pain at the time of the accident, however, she visited the same ER for that fall and her EHR denoted a complaint of head pain. X-rays were negative for fracture and exam was negative for concussion. She has been experiencing sleep issues since the fall, and withdrew abruptly from her daily six cups of coffee.

The patient explained that she had experienced periodic migraines for several years. Chronic use of acetaminophen can cause rebound headaches that appear similar to migraines. Abrupt caffeine withdrawal can also create headaches.

In this case, the patient experienced a mild traumatic brain injury (TBI) that was not initially diagnosed.  Headaches, fatigue, impaired sleep and light sensitivity are all classic signs of mild TBI.

What tests should have been performed to give a definitive TBI diagnosis? Do you agree with the TBI diagnosis?

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