The patient is a previously well 13-year-old female who presents to the emergency department (ED) with intermittent headaches for 2 years. The headaches initially occurred sporadically but have progressed in frequency and severity for the past several months to daily headaches that occur after every void, beginning 1 minute after urination, remaining severe for about 3 minutes, then subsiding to a severity of 2/10 until subsequent urination. Two days before presentation, the headaches became more severe, localized to the occipital region, and were accompanied by nausea and tingling of her hands and feet. The patient reports photophobia, phonophobia, and palpitations during the headaches but does not describe an aura. She reports no vertigo, visual changes, fever, weight loss, upper respiratory symptoms, change in urinary frequency or amount, rash, or association with menstruation. She has no headaches with bowel movements. The patient has sought medical attention for these headaches in the past, and prior evaluation included computed tomography (CT) of the head without contrast, an electrocardiogram, Holter monitor, and thyroid studies, all of which were unremarkable.
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