A 36-year-old woman comes to the office due to headaches. Over the past 3 months the patient has had constant, bilateral headaches almost every day shortly after awakening. She has had intermittent episodes of migraines since adolescence, but her current headaches are more frequent though milder. The patient has been taking over-the-counter analgesics several times a day. She has had no focal weakness, numbness, or vision changes. The patient has no other medical conditions and does not use tobacco, alcohol, or illicit drugs. Vital signs are within normal limits. BMI is 24 kg/m². Physical examination, including funduscopy and neurological examination, shows no abnormalities. Blood cell counts and serum chemistry studies are within normal limits. Which of the following is the most appropriate next step in management of this patient?

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11ec25c8_d55f_1d76_bc81_b3ae6eb05cde_MD0003_00 This patient has evidence of medication overuse headache (MOH), which is characterized by near-daily headache in the setting of regular use of acute headache medications. MOH occurs in patients with a preexisting headache disorder (eg, migraine), and the diagnosis requires symptoms to be present for ≥3 months. Patients' underlying headache disorder may worsen, such as transitioning from episodic migraine to chronic migraine (headache ≥15 days/month), or patients may develop an entirely new headache pattern. Symptoms frequently mimic a migraine-type or tension-type headache. Common features include headache that is present upon awakening (as in this patient) as well as symptom relief for only short periods, with quick rebound necessitating further medication use. The pathophysiologic mechanism is likely due to an interplay between genetic predisposition; central pain sensitization with alteration of neuronal excitability and receptor downregulation; and behavioral disorders (eg, substance dependence). Although overuse of any type of acute headache medication can lead to MOH, butalbital-containing products, acetaminophen, and opioids are the most commonly implicated drugs. Management involves cessation of the culprit drug with consideration of concomitant initiation of preventive therapy. (Choice B) Idiopathic intracranial hypertension, which is diagnosed by measuring the opening pressure during lumbar puncture, most commonly occurs in overweight or obese women of child-bearing age. It is characterized by frequent headaches and visual disturbance. Papilledema and visual field deficits are evident on examination. (Choice C) Patients with new headache and high-risk features, including age >50, fevers, "thunderclap" onset, immunosuppression, or history of malignancy, should undergo MRI of the brain to evaluate for an intracranial mass or hemorrhage. This patient lacks these features and does not warrant imaging. (Choice D) Opioids are not an appropriate therapy for the acute management of chronic headache and are associated with the development of MOH. (Choice E) Headache may be a prominent symptom in patients with anxiety or depression; however, it rarely occurs in isolation and is more commonly part of a constellation of symptoms, including fatigue, insomnia, excessive worrying, and depressed mood. Educational objective: Medication overuse headache is characterized by chronic, near-daily headache in the setting of regular use of acute headache medications in patients with a preexisting headache disorder. Common features include headache that is present upon awakening and brief symptom relief followed by rebound pain. Management involves cessation of the culprit medication. References: Medication-overuse headache: a widely recognized entity amidst ongoing debate. (http://www.ncbi.nlm.nih.gov/pubmed/30003412)

A 36-Year-Old Woman Comes to the Office Due to Headaches