How to manage chronic daily headaches and migraines with suspected medication overuse headache in a patient with iron deficiency anemia, allergic rhinitis, and asthma, who is traveling overseas?

Management of Chronic Daily Headaches with Medication Overuse Headache in a Traveling Patient

This patient has medication overuse headache (MOH) from chronic analgesic use and requires abrupt withdrawal of all overused medications, but given the overseas travel, provide a limited supply with strict counseling on minimal use, initiate topiramate for migraine prevention, and plan definitive MOH treatment upon return. 1, 2

Immediate Recognition and Diagnosis

This patient meets diagnostic criteria for MOH with clear medication overuse patterns:

• Daily paracetamol + ibuprofen use (4 times daily) exceeds the threshold of ≥15 days per month for NSAIDs 1, 2
• Chronic daily headache pattern (waking and sleeping with headache) for years indicates transformation from episodic to chronic migraine 3, 4
• The 12-year migraine history with recent escalation to daily headaches represents the classic progression of MOH 4, 5

The Core Problem: Medication Overuse Headache

Abrupt withdrawal of all overused acute medications is the necessary and only definitive remedy for MOH 2, 6. The evidence strongly supports:

• Complete cessation is more feasible and effective than restricted intake, with 44% reduction in medication dependence 2
• Non-opioid analgesics (paracetamol, ibuprofen) can be stopped abruptly without tapering 2, 6
• Codeine requires tapering due to opioid properties, not abrupt cessation 6

Critical Thresholds to Understand

• NSAIDs (ibuprofen, paracetamol): ≥15 days per month causes MOH 1, 2
• Triptans: ≥10 days per month causes MOH 1, 2
• Any acute medication should be limited to no more than twice per week (8-10 days/month) to prevent MOH 2

Management Algorithm for This Traveling Patient

Step 1: Patient Education (Critical Before Travel)

Counsel extensively that headaches will worsen before improving during withdrawal, and this worsening is expected and necessary for recovery 2, 4. Specifically explain:

• The current daily analgesic use is perpetuating and worsening the headache pattern 3, 4
• Success rate of withdrawal treatment is 50-70% at 6-12 months, but requires strict adherence 2, 4
• At least 1 month medication-free is required to determine effectiveness 2

Step 2: Preventive Therapy Initiation (Already Done Correctly)

Topiramate 25mg nocte is appropriate as it has moderate evidence for prophylactic treatment in chronic migraine with medication overuse 6. The plan should include:

• Start preventive therapy in parallel with medication withdrawal, not after 2, 6
• Efficacy requires several weeks to months; assess after 2-3 months post-travel 1, 2
• Teratogenic counseling was correctly provided; contraception is essential 1

Step 3: Acute Medication Strategy During Travel (Harm Reduction Approach)

Given the 8-week overseas travel, complete abrupt withdrawal is not feasible, so implement strict harm reduction:

Provide limited quantities with explicit instructions to use no more than 2 days per week maximum 2. Specifically:

• For acute migraine attacks (incapacitating with nausea/photophobia): Use triptan + NSAID combination 1
• Consider prescribing a different triptan than rizatriptan if drowsiness was problematic (e.g., sumatriptan, zolmitriptan) 1
• For daily headaches: Advise complete avoidance of paracetamol/ibuprofen during travel if possible 2, 6
• Omeprazole co-prescription for gastric protection if NSAIDs are used (already planned appropriately)

Step 4: Post-Travel Definitive Management

Upon return, implement complete abrupt withdrawal of all acute medications 2, 6:

• Discontinue paracetamol, ibuprofen immediately (no taper needed) 2, 6
• Taper codeine gradually due to opioid properties 6
• Continue topiramate throughout withdrawal period 6
• Consider adding corticosteroids (60mg prednisone/prednisolone) or amitriptyline (up to 50mg) for withdrawal symptom management 6

Addressing the Migraine Component

For the episodic incapacitating migraines (distinct from daily headaches):

First-line acute treatment: NSAID (ibuprofen or naproxen) + triptan combination 1. Specifically:

• Begin treatment as soon as possible after migraine onset for maximum efficacy 1
• Combination therapy (triptan + NSAID) is more effective than monotherapy and reduces recurrence 1
• Consider non-oral triptan formulations if severe nausea/vomiting present 1
• Add antiemetic (metoclopramide or domperidone) for nausea management 1, 2

Avoid opioids (codeine) and butalbital for acute migraine treatment 1—these have questionable efficacy and high risk of dependency and MOH perpetuation 1.

Special Considerations for This Patient

Iron Deficiency Anemia

• Ferritin 17 is low; continue iron supplementation as planned (general medical knowledge)
• Recheck FBC and iron studies post-travel to assess response (already planned)
• Anemia can worsen headache severity and should be corrected (general medical knowledge)

Neck Pain Component

• Chronic neck pain may contribute to headache pattern; neck exercises were appropriately provided 1
• Consider cervicogenic headache as contributing factor, though primary diagnosis is migraine with MOH (general medical knowledge)

Neurological Symptoms

• Fingertip numbness (more right-sided) warrants monitoring but with normal cranial nerve and upper limb neurological exam, likely not concerning (general medical knowledge)
• Red flags requiring urgent imaging: severe sudden-onset headache, progressive worsening, neurological deficits, headache worsened by Valsalva 1—none clearly present here

Lifestyle Modifications (Essential Component)

Implement comprehensive lifestyle changes to reduce migraine frequency 1:

• Maintain regular sleep pattern with consistent sleep/wake times 1
• Adequate hydration throughout the day 1
• Regular meals without skipping 1
• Continue weekly hiking (moderate-to-intense aerobic exercise) 1
• Stress management techniques given high-stress job 1
• Use headache diary to identify triggers 1, 2

Follow-Up Plan

Schedule follow-up 2-4 weeks after return from travel (not 8 weeks later) to:

• Assess topiramate efficacy and tolerability 2
• Implement complete medication withdrawal protocol 2, 6
• Evaluate for specialist referral if inadequate response 1—already appropriately planned
• Monitor for relapse with regular follow-up every 6-12 months 2, 6

Common Pitfalls to Avoid

• Do not confuse chronic migraine with MOH—they often coexist but require different management approaches 2
• Do not delay preventive therapy until after withdrawal; start simultaneously 2, 6
• Do not prescribe opioids or butalbital-containing compounds for migraine 1
• Do not allow patient to continue current analgesic pattern indefinitely—this perpetuates the problem 3, 4
• Warn patient that early abandonment of topiramate due to perceived inefficacy is common but should be avoided 2