Need to rule out MOH and begin a preventive, a cGRP inhibitor would likely help.

Agree with Dr Giampolo. Besides doing a thorough history etc. one must take a look at cultural factors. What comes to mind in my almost 40 years is the probability of other factors such as Cysticercosis and/ or dietary habits.

Highly likely to have medication overuse headaches. Cut back on OTC and caffeine to start. Needs to start on a prophylactic medication. Amitriptyline may help with IBS symptoms while topiramate could help with weight loss. Stopping smoking is helpful as well. Given that he has failed two triptans, there is a good chance insurance would cover Nurtec or Ubrelvy for an abortive treatment. This would be a great alternative given low side effects, higher efficacy and may phase out any medication overuse headaches he is experiencing. Involving physical therapy would likely be helpful given the tight/tender muscles in the upper back/neck. Could also consider evaluation for cervical dystonia and botox treatment for this as this could be triggering headaches. Finally, if he were to fail 2 or more generic prophylactics, he could consider a monthly CGRP injectable. Although he has the diagnosis of "chronic migraines", his history of 8 migraines a month would put him in the "episodic migraine" category for which the CGRP injectables are indicated.

Discuss with patient to stop using OTC completely. Also, if he is using too much Triptan, I will cut it down, or Do 4 weeks of Triptan Holiday. I will recommend to use Indomethacin 50mg PRN for few weeks. After that, new oral or Injectable CGRP for prevention of migraine and other CGRP for acute treatment of migraine.

Thanks, All, for your wonderful input. Medication overuse was mentioned; how would you manage this?

Imaging with MRI and MRV due to the worsening headaches and smoking history. Smoking cessation, PT for neck pain, stop caffeine and OTC analgesics. Assess for sleep apnea. Pharmacologically topiramate then CGRP injectable. For acute Nuetec.

pt as chronic miagrine. would consider elavil, may also help IBS. would consider nurtec for acute treatment

I will review previous headache work up, may need mri of the head to rule out other problems, will start prevention treatment I would begin an injectable CGRP receptor antagonist for prevention, consider new acute migraine treatment like nurtec or ubrelvy, very important to discuss precipitating factors

Agree with most of the comments, a new history should be done and evaluations as to OTC medication consumption. Reduction of smoking is recommended as nicotine is a vaso constrictor and too many OTC meds ( ibuprofen, Naprosyn, opioids antihistamines too much caffeine and others) offer complex issues to the migraine suffer. Lastly upon fully developing this patients history, diagnosis, co-morbid symptoms, episodes and outcome as to any triggers, the use of a calcitonin gene agonist may be useful. As there are several of these currently on the market a trial of such would be recommended. Tom Kaye

This patient seems to have chronic migraine headache. If this was my patient, I would take a step back and try to get a thorough history and physical exam (including a complete neuro exam and vision exam), social history, family history and other stressors that he may have. What are the aggravating and relieving factors? Review any labs or imaging tests that are available. It might also be beneficial for this patient if he is being managed by just one physician, for someone to really focus on him and minimize polypharmacy. Would advise him to start a headache diary if he has not already. Also lifestyle modification, such as healthy diet, increasing hydration, exercise, lessening caffeine intake and smoking counseling.

Lifestyle issues seem like a major contributor to these issues. Would assess for patients interest and ability to modify any of the previous noted issues. Also consider Botox

Thanks, All, for your wonderful input! What role does lifestyle modification play in this case? How would you advise the patient?

I would address chronic issues, ie weight loss, smoking cessation. I would begin an injectable CGRP receptor antagonist for prevention. The compliance is very low with other preventative therapies. Sounds like he would be good candidate for Botox. Agree with discontinuing OTC meds as medication overuse headache is certainly possible. A gepant for acute migraine, maybe in addition to the triptans. Would recommend coffee cessation as caffeine withdrawal may be playing a role. As his headaches have worsened, might consider an imaging study. Physical therapy referral for neck/shoulder pain.

I would recommend the patient start magnesium supplementation daily and a thorough discussion needs to be had to eliminate other headaches - such as tension ones as possible also. Stress management and a full evaluation of sleep habits and quality need to be looked at as well. It is very likely that there are some sleep issues given the history. The timing of caffeine and nicotine and alcohol use needs to be looked at also -not just their use. It is worth looking into his job environment as a source of stress and likewise his family / support. Obviously a look at metabolic disorders needs to be done if not looked at recently.

Agree with everyone's comments about stopping OTC meds and the rebound effect. I would consider thiamine and magnesium supplementation for prevention and consider topomax which also might help with weight loss

He is a smoker and overweight so would lose the triptans which are causing headache allodynia. I would start Nurtec ODT QOD or a parenteral CGRP which may significantly decrease his headaches without heightened CV risk. He must stop smoking.

This patient may have chronic migraines but there are other co-morbid conditions to consider as well. IBS, tobacco abuse, weight gain, cervalgia may have a psychological component that can precipitate med overuse. Can switch to Gepants preferably injectables. Then once the headaches are under control address all the other conditions.

The patient definitely meets criteria and would start CGRP prophylactic treatment. Patient needs to stop the OTC analgesics and would consider low dose Elavil hs if this is too difficult.

This patient would benefit from prophylactic therapy, and OTC analgesics should be limited to prevent rebound headaches. A gepant may be a good addition for abortive therapy. Botox may be of some benefit in this patient, but he would likely need to have tried several other prophylactic medications before insurance will approve it. A TCA would not be the best choice in this patient due to the side effect of weight gain. Bottom line is this patient definitely needs QOL improvement!

This patient definitely has rebound and medication overuse headaches-need to start preventive therapy with topamax or any other available change abortive treatment to one that works best for him to include CGRP antibody.

Chronic migraine h/a disorder as well as medication overuse h/a. Definitely needs to be on preventative therapy. Cervicalgia is part of his migraines. Topamax would be a good choice because of potential to have some weight loss. Abortive therapy with a gepant is probably appropriate. Also need to counsel the patient that cigarettes may well interfere with the efficacy of migraine therapy.

First bridge him with medication to get him off OTC medications, there is a medication overuse component. Start a preventative agent. This would be based on prior failures and other medical issues. Possible Topamax if hasn’t tried in the past or a anti CGRP. For abortive therapy switch to a newer agent. Such as Ubrevly or Nurtec along with Reglan. Needs to be counseled on
Triggers and Lifestyle. Cervicalgia-PT, or another modality that he is in agreement with. He needs to be seen on a routine basis and keep a strict migraine diary.

Review possible contributing factors including caffeine intake, sleep patterns and analgesics that might be causing rebound headaches. Certainly consider injectables.

THis patient needs to stop his otc analgesics, it is most likely causing rebound headaches. He needs to be put on a preventative medication, if his insurance covers it, a CGRP would be bet, however, he many need to try a generic first, like topamax or elavil, etc. He also needs to start a CGRP for abortive therapy, while he can still use his triptans if he wants, another tool to help with the abortive treatment always helps.

I think this patient has medication overuse migraines. Would strongly consider titrating off triptans. Need to try ubtelvy or nuttec. Needs prophylactic therapy. If never tried any agents, beta blocker, topama or anti depressant. Also change of life style. Test for OSA

Factors to consider are his caffeine use, stress and amount of sleep he is getting.
His other medications could be an influencing factor. Other calcium channel blockers could be used in addition to the triptans.

This clinical vignette may be a fictional case, but patients with many concurrent co-morbid clinical conditions and risk factors for migraine headaches are quite common in neurology practices specializing in headache management. We are told that this patient “has been diagnosed with chronic migraine.” However, especially for patients with increasing disability due to their headaches, it is prudent to maintain a clinical suspicion for other potential secondary headache disorders as a cause of their increasing headache symptoms. (Chiang et al, 2020, Numerous modifiable risk factors (Crain, 2021, https://cdn.mdedge.com/files/s3fs-public/JFP07001020.PDF) and migraine “triggers” (American Migraine Foundation, 2017, https://americanmigrainefoundation.org/resource-library/top-10-migraine-triggers/) for increasing headache frequencies have been described Efforts to reduce these associated modifiable risk factors and “triggers” should be addressed. I agree with my above colleagues that preventive therapy should be recommended for such a patient with frequent and disabling headaches. (Ailani et al, 2021, https://headachejournal.onlinelibrary.wiley.com/doi/epdf/10.1111/head.14153) I concur with my fellow commenters that the patient's presumed frequent use of various abortive, symptomatic, and OTC analgesic medications (taken as few as 10 days per month [Tsakadze et al, 2018, https://practicalneurology.com/articles/2018-feb/medication-overuse-headache] for the treatment of headaches is suggestive of a concurrent medication overuse headache (MOH) diagnosis. MOH is managed by the patient limiting the use of these symptomatic treatments and often starting a preventive treatment and/or short-term use of bridging or transitional therapy (Garza et al, 2021, https://www.uptodate.com/contents/medication-overuse-headache-treatment-and-prognosis#H16).

Screen for anxiety and depression. Consider venlafaxine if elevated. He needs something for prophylaxis and I would recommend a cgrp. Smoking cessation should be started also.

I would absolutely start him on either Nurtec or Ubrevly. Would try to taper the triptans. Would recommend weight loss as well. Would also consider Botox for migraines and/or Torticollis as another treatment option.

I would recommend a -gepant as an abortive, which would have minimal side effects including GI upset. also they do not interfere with other meds he might be using. In terms of increasing headache I would ask how much caffeine is he drinking- he might be drinking too much causing caffeine overuse headaches. also taking a history of possible sleep apnea given high BMI is worth looking into. If he wants to, nurtec can both be used as an abortive and preventative so would be a good option. Ubrelvy prn and trying topamax for it's weight loss side effect is also a good option as well.

This patient’s primary diagnosis certainly meets criteria for chronic migraine. There may be several factors that contribute to his worsening headache. Medication overuse is likely playing a role and should be counseled against. The patient’s less severe headache has some migraine features but also has features of occipital neuralgia. The patients neck pain and tenderness are likely what is contributing. Botox would be a good option for this patient because it would likely improve both problems. I find that patients do very well with this intervention with these same clinical features. I would consider starting a low dose muscle relaxer with an in office occipital nerve block. I also like the idea of combining this with an injectable cgrp as these are highly effective at reducing migraine frequency and severity and are well tolerated.

Chronic migraine, not doing well with prior treatment. Would start on prevention Nurtec or Qulipta immediately and taper analgesics. May use the triptan 2-3 days weekly initially. After a couple of weeks would start tapering topiramate.

This patient meets the criteria for a diagnosis of chronic migraine without aura, probably with analgesic overuse and associated myofascial neck pain. I would determine the frequency of prn analgesic use (combined rx and OTC analgesic use) and discontinue over the counter analgesics if usage frequency is at least days monthly. He should limit his triptan use to no more that 2 days weekly and may consider an alternative triptan, DHE, or gepant if he is having an inadequate abortive response. Concurrently, aggressive prophylaxis with an appropriate oral agent such as topiramate is needed. Would also consider botulinum toxin or a CGRP antibody depending on response to topiramate. Minimizing caffeine, alcohol and smoking cessation would be recommended. Would counsel on sleep hygiene, recommend regular exercise, starting a headache diary, completing elimination diet, and could offer massage or acupuncture adjunctively for headache control and neck pain. Stress reduction and evaluation for any comorbid mental health conditions which may be exacerbating his migraines and IBS are needed.

This patient has chronic migraine that has increased in frequency over time. It is important to look for medication overuse and strongly consider adding on a preventive. If they have not previously tried a preventive, then it can be useful to start with an oral migraine non-specific medication, although Botox may also be a good option if insurance will cover it. Other behavioral modifications like yoga or mindfulness will also be helpful, as well as addressing if there are any lifestyle issues like trouble sleep and increased stress.