Migraine treatment

A 33-year-old woman attends her six-month follow-up appointment for headache.They are migrainous in nature but whereas she used to have them every few months, over the last three months she has experienced a chronic daily headache which varies in location and can be anywhere from 3–7/10 severity. Her last migraine with aura was two months ago. She takes co-codamol qds and ibuprofentds. What is the best medical management?

A. Stop all medication

B. Start paracetamol

C. Start sumatriptan

D. Start propranolol

E. Continue current medication


Ans: A This woman has developed analgesia (rebound) headache as a result of over-using co-codamol and ibuprofen. Starting paracetamol (B) would result in overdose as it is already contained in co-codamol. The treatment is to withdraw analgesics (A) which initially will worsen the headache (the patient should be prepared for this) but in the long run will alleviate it. It is not advisable for headache patients to take simple analgesia more than 2 days a week. Once she is off the analgesia, it will be easier to discern the effect of her migraines. She may require abortive sumatriptan (C) to be taken as soon as the headache starts or prophylactic beta blockers (D) taken daily. Continuing her current medication (E) will not improve matters.

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