A 30-year-old woman with a history of episodic migraine headaches comes to the office due to worsening of her headaches. She started having infrequent migraine headaches in her early twenties. However, her migraine headaches have become more severe over the past 1 year and have started to occur >15 days/month. She has been taking ibuprofen on a daily basis for months to treat the headaches, which have only worsened and now occur on a daily basis. Recent MRI of her brain showed no abnormalities. She has not had any fevers, neck stiffness, vision changes, head trauma, double vision, dysarthria, dysphasia, weakness, numbness, or difficulty with balance. Her headaches are not affected by changes in head position, cough, or Valsalva maneuvers; but are made worse by physical activity and are associated with photophobia, and nausea. She works as a secretary and has needed to take leave from work due to her severe headaches. She does not use tobacco, alcohol, or illicit drugs.
Her seated blood pressure is 128/76 mm Hg and pulse is 76/min. Her BMI is 32 kg/m².
Neurologic examination shows no abnormalities except for marked photophobia. Which of the following is the most appropriate next step in the management of this patient?

Question

Quizplus · Accepted Answer

This patient presents with medication-overuse headache (MOH) in the setting of transformed migraine (ie, chronic migraine). Chronic migraine is defined as a unilateral headache (with or without aura) that is worsened by physical activity; associated with photophobia/phonophobia/osmophobia, nausea or vomiting, and occurs >15 days/month for >3 consecutive months in the absence of any secondary causes. MOH can occur in the setting of a primary headache disorder (eg, migraine) when a patient takes daily analgesics (eg, nonsteroidal anti-inflammatory drugs, butalbital plus aspirin plus caffeine, acetaminophen, triptans, opiates, etc) for >15 days/month. The table lists the most common medications associated with MOH. 11ec193a_9874_038d_853d_fd510dc7fe4e_MD0002_00 MOH can be very difficult to treat and requires immediate discontinuation of the offending analgesic agent. Patients typically have significant worsening of their headaches after discontinuing the analgesic agent; therefore, they require a bridging agent (usually a short 1-2-week course of oral steroids) to help control the headache. In addition to MOH, this patient also has a chronic migraine headache and needs to be started on a migraine preventive (eg, topiramate). Topiramate is a good choice for this patient because she has obesity and will benefit from the medication's weight-loss side effect. (Choice B) A lumbar puncture to check for opening pressure is indicated in a patient who is clinically suspected of having idiopathic intracranial hypertension (IIH) (ie, pseudotumor cerebri). The clinical features of IIH include chronic daily headache, visual changes, worsening of the headache with lying flat, and increased cerebrospinal fluid opening pressure. MRI abnormalities (eg, posterior scleral flattening, empty sella) may be seen. This patient's headaches do not worsen with lying flat, she has not had any visual changes, and her MRI is normal. (Choice C) An MRV of the head is indicated to exclude cerebral sinus venous thrombosis in patients who have clinical findings suggestive of increased intracranial pressure (eg, papilledema, transient visual obscurations, and worsening of headaches with cough, Valsalva maneuver, or lying flat). This patient's normal MRI of the brain makes this diagnosis very unlikely. (Choice D) Acetazolamide is a carbonic-anhydrase inhibitor that is indicated for the treatment of IIH. (Choice E) This patient also has MOH, which is not addressed by starting topiramate alone. Educational objective: Medication-overuse headache (MOH) can present in the setting of a primary chronic headache disorder. It needs to be addressed separately from the chronic headache disorder by the discontinuation of the offending analgesic agent and the introduction of a short oral steroid taper. __________ References: Update on medication-overuse headache (http://www.ncbi.nlm.nih.gov/pubmed/21058047) Transformed migraine and medication overuse in a tertiary headache centre--clinical characteristics and treatment outcomes. (http://www.ncbi.nlm.nih.gov/pubmed/15154858)

A 30-Year-Old Woman with a History of Episodic Migraine Headaches