Headache

Abstract

Ms. Sharpe is a 38-year-old high school administrator. She describes incapacitating headaches associated with vomiting that take her to bed. She reports having troublesome headaches two to three times a week, although she rarely misses work for headache. She does report that her family becomes angry with her for wanting to spend Friday evenings in bed rather than going to the movies or some other family activity. She has never found relief from analgesics or triptans. Her primary care physician (PCP) prescribes a nighttime dose of amitriptyline and arranges a follow-up visit in 3 weeks. Three weeks later, she reports no headache improvement and her PCP subsequently prescribes trials with propranolol, verapamil, and valproate, all without relief. At this point, Ms. Sharpe is given a daily headache-recording diary, which she is asked to keep over the next month. When the diary is reviewed, her PCP notes that, in addition to the one or two severe migraine episodes each week, she also records a daily headache that fluctuates in severity between mild and moderate, lasting most of the day. She also records daily use of four to six tablets of Excedrin per day, four ibuprofen tablets 3 days a week, and Imitrex twice a week. In her history, she also notes drinking approximately six cups of coffee daily. Because excessive use of analgesics, caffeinated products, and other acute care medications (e.g., triptans) typically aggravates underlying headache disorders, Ms. Sharpe’s PCP asks her to discontinue all acute therapies and limit coffee to two cups a day. She is also prescribed Relafen twice daily as treatment for rebound headache, and is allowed to take one additional Relafen dose on days with severe headache. One month later, she reports that she is no longer having daily headache, but still has a severe migraine once a week. This is easily managed with infrequent use of Imitrex, which had previously proven ineffective when taken in conjunction with daily analgesics.