Medication overuse headache

Case history

A 35-year-old woman with a history of infrequent migraine episodes since she was a teenager presents with a gradually progressive worsening of headache over the past year. Initially, she had more stress from work and started to take paracetamol on a frequent basis for her increasingly frequent headaches, but the benefit wore off over time. Her family physician prescribed sumatriptan, which provided effective relief for a few months, but over the past 3 months she has been experiencing daily headaches despite using sumatriptan on most days. Her headache is holocephalic, moderate to severe in intensity, and occasionally associated with nausea and vomiting and sensitivity to light and sound. She reports no visual or headache pattern changes but has experienced worsening neck pain in conjunction with her headache, particularly a few hours after work. The headaches are not triggered by postural changes, exertion, or cough, except for head motion. On examination, no papilloedema is observed; mild scalp allodynia and mild jaw and upper neck tenderness are noted. There are no signs of joint hypermobility, focal weakness, numbness, or other neurological deficits. The persistent nature of her headaches has caused her to become depressed and she has had to take a leave of absence from work.