What is the best course of treatment for a patient with severe anxiety, stress migraines, and chronic headaches, currently taking paracetamol and ibuprofen for migraines, and Mounjaro (tirzepatide)?

Treatment Approach for Severe Anxiety, Stress Migraines, and Chronic Headaches

Immediate Acute Migraine Management

Your patient requires escalation from paracetamol/ibuprofen to more effective acute therapy, as paracetamol has inferior efficacy (NNT 12) and should only be used when NSAIDs are contraindicated. 1, 2

First-Line Acute Treatment Modifications

• Switch to naproxen sodium 500-825 mg at migraine onset (when pain is still mild), which has stronger evidence than ibuprofen for migraine treatment 1, 3
• If naproxen fails after 2-3 migraine episodes, escalate to a triptan (sumatriptan, rizatriptan, or zolmitriptan) for moderate-to-severe attacks 1, 3
• Add metoclopramide 10 mg orally 20-30 minutes before the analgesic to provide synergistic analgesia and address nausea, even if vomiting is not present 3

Critical Medication Overuse Warning

• Limit all acute medications to no more than twice weekly to prevent medication-overuse headache, which can transform episodic migraine into chronic daily headache 1, 3
• Current paracetamol/ibuprofen use frequency must be assessed immediately—if exceeding twice weekly, medication-overuse headache may already be present 1

Preventive Therapy Initiation (Priority Action)

Given work disability since the specified date and ongoing stress triggers, preventive therapy should be initiated immediately rather than waiting for the follow-up appointment. 1

Optimal Preventive Agent Selection

• Amitriptyline is the single best choice for this patient, as it treats both migraine prevention and comorbid anxiety/depression with one agent 4
• Alternative options if amitriptyline is contraindicated: topiramate (proven efficacy in chronic migraine) or divalproex sodium 1, 4
• Avoid flunarizine and beta-blockers initially despite their use in anxiety, as amitriptyline provides superior dual benefit for this presentation 4

Preventive Therapy Expectations

• Efficacy requires 2-3 months for oral agents—set realistic expectations with the patient 3
• Continue preventive therapy for at least 6-12 months after achieving headache control 1

Anxiety Management Integration

Pharmacologic Approach

• If amitriptyline alone is insufficient for anxiety control, add an SSRI or SNRI (these are first-line for both depression and anxiety disorders) 4
• Consider pregabalin if anxiety is severe and refractory, as it has demonstrated efficacy in anxiety disorders 4

Non-Pharmacologic Interventions (Essential Component)

• Initiate cognitive-behavioral therapy immediately—it has good evidence for both anxiety disorders and migraine prevention 4, 5
• Implement relaxation training and biofeedback as first-line preventive options with strong evidence from randomized trials 5
• Stress management is critical: behavioral interventions help modify responses to work-related stressors without requiring avoidance behaviors that damage quality of life 1

Mounjaro (Tirzepatide) Considerations

• No contraindications exist between tirzepatide and migraine medications 1
• Monitor for nausea as a side effect of tirzepatide, which could complicate migraine-associated nausea 3
• Weight loss from tirzepatide may improve migraine outcomes if obesity is present, as obesity is a modifiable risk factor for chronic migraine 1

Work Disability Documentation

• Maintain a headache diary documenting frequency, severity, duration, disability, and medication response—this is essential for both treatment optimization and medical certification 1
• Document specific work limitations: inability to perform duties during attacks, photophobia/phonophobia in work environment, cognitive impairment from pain 1

Critical Pitfalls to Avoid

• Do not allow continued frequent use of paracetamol/ibuprofen—this creates medication-overuse headache and worsens the underlying condition 1, 3
• Do not delay preventive therapy until the scheduled follow-up—work disability and frequent headaches are clear indications for immediate initiation 1
• Do not prescribe opioids or butalbital-containing compounds for this patient, as they lead to dependency, rebound headaches, and loss of efficacy in chronic headache patterns 1, 3, 6
• Do not treat anxiety and migraine as separate conditions—the comorbidity alters migraine course, increases disability, and promotes chronification if not addressed simultaneously 4

Follow-Up Timeline

• Reassess acute medication frequency within 2 weeks to ensure medication-overuse headache is not developing 1, 3
• Evaluate preventive therapy response at 4-6 weeks, with full efficacy assessment at 2-3 months 1, 3
• If headaches persist despite optimized therapy, consider referral to neurology or headache specialist for advanced options (CGRP antagonists, onabotulinumtoxinA) 1, 3