Thursday, August 29, 2013

Back to the Drawing Board

A 30 year old woman with anxiety and longstanding migraines comes in with severe head pain despite "trying everything." Her headache history starts as a teenager when she had classic migraine symptoms of unilateral head pain lasting 24 hours triggered by poor sleep, stress, or poor eating habits, associated with nausea, vomiting, photophobia, and phonophobia. These were treated with NSAIDs and acetaminophen.

However, in her late 20s, her migraines started happening more and more frequently. She started taking compounds containing acetaminophen, hydrocodone, oxycodone, butalbital, caffeine, aspirin, and ibuprofen with some relief. She now takes multiple medications a day including a daily triptan. Despite trying everything, she currently suffers a constant debilitating headache present when she wakes up in the morning. She gets some relief from her medications but never enough. She also has nausea, difficulty concentrating, and irritability. Her vital signs and neurologic exam are normal.

Challenge: She asks if she has a brain tumor or if you have another medication or why her migraines have gotten so bad. What do you say?

Image of Fioricet is in the public domain, from Wikipedia.

2 comments:

sibogox said...

her chronic headache currently might be due to excessive use of medication.. she gets it in the morning because she doesn't take any when she sleeps hence the drug withdrawal headache in the morning

Craig Chen said...

yep!
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Back to the Drawing Board

This is medication overuse headache (also called analgesic rebound headache, drug-induced headache, and medication misuse headache) which coexists with a primary daily chronic headache and can interfere with proper treatment of the primary headache. Treatment is to stop the excessive use of breakthrough analgesics.

Source: UpToDate.