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Stem
A 28-year-old female office worker presents to her GP with a 6-month history of recurrent headaches. They occur about twice a week, last most of the day, affect the right temple and forehead, are described as "throbbing", are rated 7/10, and force her to stop working and lie still in a dark, quiet room. She feels nauseated and is sensitive to light and sound. There is sometimes a 20-minute warning of "shimmering zigzag lines" in her vision before the pain begins. She has been taking ibuprofen and codeine/paracetamol combination tablets on 12 days a month for the past 3 months, with diminishing effect. Examination, including blood pressure, fundoscopy, and a full neurological assessment, is normal.[1]
Questions
a) What is the diagnosis, and which ICHD-3 criteria support it? (2 marks)[1]
Migraine with aura. At least 5 attacks of unilateral, throbbing, moderate-to-severe headache lasting 4 to 72 hours, aggravated by routine activity, with nausea and photophobia/phonophobia; the visual aura (scintillating scotoma) develops over 5 minutes and resolves within 60 minutes, followed by headache.[1]
b) What additional headache diagnosis has now emerged, and what defines it? (2 marks)[1]
Medication-overuse headache (MOH): headache on 15 or more days/month for over 3 months in a patient with a pre-existing primary headache, caused by regular analgesic overuse (combination analgesics/opioids/triptans on 10 or more days/month for over 3 months).[1]
c) Outline the stepwise management. (4 marks)
- Acute therapy: oral sumatriptan 50 to 100 mg (or 20 mg intranasal / 6 mg subcutaneous if vomiting) with an antiemetic (metoclopramide 10 mg); treat early in the attack before central sensitisation.[1]
- Withdraw the overused codeine/paracetamol combination immediately (the definitive treatment for MOH); bridge with naproxen or a short prednisolone taper.[1]
- Start prophylaxis (headache on over 4 days/month): first-line propranolol 40 to 160 mg twice daily, or topiramate, amitriptyline, or a CGRP monoclonal antibody (erenumab, fremanezumab, galcanezumab).[1]
- Non-pharmacological: regular sleep/meals, trigger avoidance, hydration.[1]
d) Name two contraindications to triptans and the underlying mechanism of action. (2 marks)[1]
Mechanism: 5-HT1B/1D receptor agonists — vasoconstriction (1B on meningeal vessels) plus inhibition of neuropeptide release (1D on trigeminal terminals). Contraindications: ischaemic heart disease (or prior MI, Prinzmetal angina) and uncontrolled hypertension; also hemiplegic/basilar migraine and pregnancy.[1]
Marking scheme
| Criterion | Marks |
|---|---|
| Correct diagnosis (migraine with aura) + 2 ICHD-3 features | 2 |
| Recognition + definition of MOH | 2 |
| Acute therapy (triptan dose/route) + analgesic withdrawal + prophylaxis + lifestyle | 4 |
| Triptan mechanism (5-HT1B/1D) + 2 contraindications | 2 |
References3ShowHide
- [1]Eigenbrodt AK, Ashina H, Khan S, et al. Diagnosis and management of migraine in ten steps Nat Rev Neurol, 2021.PMID 34145431
- [2]Perry JJ, Stiell IG, Sivilotti MLA, et al. Clinical decision rules to rule out subarachnoid hemorrhage for acute headache JAMA, 2013.PMID 24065011
- [3]Holroyd KA, O'Donnell FJ, Stensland M, et al. Management of chronic tension-type headache with tricyclic antidepressant medication, stress management therapy, and their combination JAMA, 2001.PMID 11325322