What is the best treatment approach for a patient with chronic daily headaches and migraines, currently using ibuprofen and paracetamol, with a history of iron deficiency anemia and asthma?

Management of Chronic Daily Headaches with Medication Overuse

This patient has medication-overuse headache (MOH) from excessive analgesic use and requires immediate withdrawal of all acute medications, transition to preventive therapy, and strict limitation of rescue medication to prevent perpetuating the cycle. 1

Critical Diagnosis: Medication Overuse Headache

This patient is taking ibuprofen plus paracetamol "4 sets throughout the day before previous dose wears off," which clearly exceeds the twice-weekly threshold and meets criteria for MOH. 2, 1

• MOH occurs when acute medications are used more than twice weekly, leading to transformation of episodic headaches into chronic daily headaches 2, 1
• The patient's pattern of daily headaches ("wakes with headache, goes to bed with headache") is pathognomonic for medication overuse 2, 1
• Codeine use at night further compounds the problem, as opioids lead to dependency, rebound headaches, and eventual loss of efficacy 2, 1

Immediate Management Steps

1. Discontinue All Overused Medications

Stop ibuprofen, paracetamol, and codeine immediately - continuing these medications will perpetuate the chronic daily headache pattern. 2, 1

• Explain that these medications are now causing more headaches than they relieve 2, 1
• Warn the patient that headaches may temporarily worsen for 2-10 days during withdrawal before improvement begins 2

2. Initiate Preventive Therapy

Start topiramate or propranolol as first-line preventive therapy given the chronic migraine pattern and need to reduce attack frequency. 2

• Preventive therapy is indicated when headaches impair quality of life despite optimized acute therapy, or when acute medications are used more than 2 days per week 1
• Efficacy requires 2-3 months for oral preventive agents 1
• Alternative: Consider amitriptyline (though previously discontinued due to mood changes in this patient) or venlafaxine as second-line options 2

3. Strictly Limit Acute Medication Use

Prescribe naproxen 500-825 mg for true migraine attacks only, with strict instructions to use no more than twice weekly. 1

• Naproxen has superior efficacy compared to paracetamol alone (NNT 5.0 vs 12 for 2-hour pain-free response) 1, 3
• Add metoclopramide 10 mg to be taken 20-30 minutes before naproxen for synergistic analgesia and treatment of nausea 1, 4
• If naproxen fails after 2-3 migraine episodes, escalate to a triptan (sumatriptan, rizatriptan, or zolmitriptan) 1

4. Address the Iron Deficiency Anemia

Optimize iron supplementation as there is an association between iron deficiency anemia and migraine incidence, particularly in females. 5

• Continue Maltofer 100 mg, but verify compliance and check ferritin levels 5
• Iron deficiency may contribute to migraine frequency and severity in this patient 5

Specific Contraindications and Cautions in This Patient

Avoid Triptans Initially

• Previous rizatriptan caused drowsiness 1
• However, failure of one triptan does not predict failure of others - if naproxen fails, try a different triptan such as sumatriptan or zolmitriptan 1

Asthma Considerations

• NSAIDs can be used cautiously, but monitor for aspirin/NSAID-induced asthma 1
• Continue Salbutamol and Flixonase as prescribed 1

Absolutely Avoid

• No further codeine or opioid prescriptions - these cause dependency, rebound headaches, and loss of efficacy 2, 1
• No butalbital-containing compounds for the same reasons 1

Travel Medication Supply (2-Week Trip)

Provide limited rescue medication only:

• Naproxen 500 mg × 4 tablets maximum (for twice-weekly use only) 1
• Metoclopramide 10 mg × 4 tablets 1, 4
• Do not provide codeine, ibuprofen, or paracetamol as these perpetuate MOH 2, 1

Non-Pharmacological Interventions

Implement lifestyle modifications and behavioral therapy as essential components of chronic migraine management. 2

• Cognitive-behavioral therapy (CBT) and biofeedback have demonstrated efficacy 2
• Regular exercise (40 minutes three times weekly) is as effective as topiramate for migraine prevention 2
• Maintain headache diary to identify triggers and monitor medication use 2
• Ensure adequate hydration, regular meals, and consistent sleep patterns 2

Red Flags Requiring Further Evaluation

The patient reports "numbness fingertips, more right side" and "feels like someone hit back of head" - these atypical features warrant neurological examination and potentially neuroimaging to exclude secondary causes. 2

Critical Pitfall to Avoid

Do not allow the patient to increase frequency of acute medication use in response to treatment failure - this creates a vicious cycle of MOH. 1 Instead, transition to preventive therapy while strictly limiting acute treatment to twice weekly maximum. 2, 1