Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 38-year-old woman is evaluated in the office for a 10-month history of increasingly frequent headache. The headache is often worse in the morning on awakening. She has recently started keeping a headache diary, which reveals episodes on approximately 25 days of each month. The headache varies from a near-daily bilateral frontal dull throbbing to a severe left hemicranial throbbing associated with nausea, photophobia, and phonophobia. The patient has a 20-year history of migraine without aura and a history of depression. Her mother also has a history of migraine and depression, and her sister has a history of migraine. The patient has been taking propranolol for 3 months; a mixed analgesic containing butalbital, caffeine, and acetaminophen for mild or moderate headache at least 3 days per week for 9 months; rizatriptan for severe headache at least 2 days per week for 4 months; and citalopram for 1 year. Rizatriptan has become increasingly ineffective over the past month.

Physical examination findings, including neurologic examination findings, are normal.

Which of the following is the most likely diagnosis for her current symptoms?

A) Chronic migraine
B) Chronic tension-type headache
C) Idiopathic intracranial hypertension
D) Medication overuse headache

MKSAP Answer and Critique

The correct answer is D) Medication overuse headache. This item is available to MKSAP 15 subscribers as item 49 in the Neurology section. More information about MKSAP 15 is available online.

This patient has medication overuse headache. She has a 20-year history of migraine but a 10-month history of chronic daily headache on more than 15 days per month. She has been using an acute headache medication (butalbital, caffeine, and acetaminophen) more than 10 days per month and a combination of this medication and rizatriptan on some of these days. These features define a medication overuse headache.

Although the patient does have chronic migraine, her current symptoms most likely result from her overuse of acute medications and not from her long history of migraine. Medication overuse headache typically presents when or soon after a patient awakens, and the efficacy of migraine-specific therapy in patients with medication overuse headache is intermittent or poor. Furthermore, some of this patient’s headaches lack the classic features of migraine, including a pounding, unilateral headache of approximately 1 day’s duration associated with nausea and disability (taking to bed).

Despite the patient’s depression, her headaches are not fully characteristic of chronic tension-type headache, which is typically mild to moderate in severity, lasts from 30 minutes to 7 days, and is often described as a “band-like” constriction around the head. Tension-type headaches are not associated with nausea and vomiting, photophobia, or phonophobia.

Idiopathic intracranial hypertension is a disturbance of increased intracranial pressure without evidence of intracranial disease, such as mass lesion, hydrocephalus, or venous sinus thrombosis. This disorder occurs most commonly in obese women of childbearing age but also may be associated with tetracycline therapy, oral contraceptive use, and hypervitaminosis A. Affected patients typically develop new onset of daily nonthrobbing headaches that may worsen with coughing and sneezing or in the supine position. Other clinical symptoms may include diplopia, transient episodes of monocular or binocular visual loss, and pulsatile tinnitus. Characteristic findings in patients with this condition are papilledema, an enlarged blind spot or visual field abnormalities, and possible sixth cranial nerve palsy. This patient’s findings are not consistent with idiopathic intracranial hypertension.

Key Point

• Medication overuse headache is generally defined as a headache for more than 15 days per month and the use of acute headache medication on more than 10 days per month.

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