What is the best course of management for a 41-year-old female with chronic headaches, primarily dull but occasionally severe, lasting over 2 months with no findings on magnetic resonance imaging (MRI)?

Management of Chronic Headache with Normal MRI in a 41-Year-Old Woman

This patient most likely has chronic migraine and should be started on prophylactic medication (topiramate, valproate, beta-blockers, or onabotulinumtoxinA) while limiting acute medications to prevent medication overuse headache. 1, 2

Diagnostic Considerations

This presentation meets criteria for chronic daily headache, defined as headache on ≥15 days per month for at least 3 months. 3, 4 Given the normal MRI, secondary causes have been appropriately ruled out, as neuroimaging is indicated for headaches that have worsened and persisted for 2 months. 2

The most likely diagnosis is chronic migraine, which requires ≥15 headache days per month for >3 months, with ≥8 days meeting migraine criteria (the "overbearing" episodes likely represent these migraine days). 2, 5

Critical Assessment: Medication Overuse Headache

You must immediately assess for medication overuse headache, as this is the most common perpetuating factor in chronic daily headache. 2, 3 Ask specifically about:

• NSAIDs or acetaminophen: ≥15 days/month indicates overuse 2
• Triptans or combination analgesics: ≥10 days/month indicates overuse 2
• Opioids or butalbital: any regular use is problematic 6, 2

If medication overuse is present, the patient must discontinue all acute medications entirely before prophylactic treatment will be effective. 3

Treatment Algorithm

Step 1: Acute Treatment Strategy

For the severe weekly episodes, prescribe acute therapy with strict limits:

• First-line: NSAIDs (ibuprofen, naproxen) or aspirin-acetaminophen-caffeine combination for mild-to-moderate attacks 1, 7
• For moderate-to-severe attacks: Triptans (sumatriptan 50-100 mg) 1, 2, 8
• Strict limit: Use acute medications no more than 9 days per month to prevent medication overuse headache 2
• Add antiemetics (metoclopramide or prochlorperazine) for nausea and synergistic pain relief 6, 2
• Avoid opioids and butalbital completely 2

Step 2: Prophylactic Treatment (Essential)

Prophylactic medication is mandatory for this patient given the chronic daily pattern. Start one of the following first-line agents:

• Topiramate 1, 3
• Valproate 1, 3
• Beta-blockers (propranolol) 1, 3
• OnabotulinumtoxinA specifically for chronic migraine 1

Additional prophylactic options include amitriptyline, gabapentin, or tizanidine. 3

Steroids have no role in chronic migraine prophylaxis and should only be considered for status migrainosus (a prolonged, unremitting migraine attack). 1

Step 3: Non-Pharmacologic Interventions

Implement these alongside medication:

• Relaxation techniques and cognitive behavioral therapy 3
• Acupuncture 3
• Regular sleep schedule, hydration, regular meals, physical activity, and stress management 2
• Maintain a headache diary to track frequency, severity, triggers, and medication use 2

Follow-Up and Referral

• Reassess in 4-6 weeks to evaluate response to prophylactic therapy 3
• Consider neurology referral if diagnosis remains uncertain, if there is poor response to prophylactic strategies, or if the patient has persistent aura or associated motor weakness 2, 9
• Educate about the importance of limiting acute medications to prevent transformation to medication overuse headache 2

Common Pitfalls

• Failing to identify and address medication overuse: This is the most common reason for treatment failure in chronic daily headache 2, 3, 4
• Prescribing acute medications without prophylaxis in a patient with chronic daily headache 3
• Using opioids or butalbital, which lead to dependency, rebound headaches, and loss of efficacy 6, 2
• Not setting clear limits on acute medication use (the 9-day-per-month rule) 2