What is the diagnosis and management plan for a 30-year-old female junior high school teacher with a 10-year history of recurrent, severe, throbbing headaches, nausea, and photophobia, now occurring almost daily with increased severity?

Diagnosis: Chronic Migraine with Medication-Overuse Headache

This patient has chronic migraine that has transformed from episodic migraine, complicated by medication-overuse headache from daily paracetamol use. 1, 2

Differential Diagnoses

Primary Diagnosis: Chronic Migraine with Medication-Overuse Headache

• Chronic migraine criteria are met: ≥15 headache days/month for >2 months (she reports "almost 5x a week"), with original attacks fulfilling migraine without aura criteria (unilateral, throbbing, moderate-to-severe intensity, with nausea and photophobia, lasting 4-72 hours) 1, 2
• Medication-overuse headache is present: Regular paracetamol use ≥15 days/month for >2 months (she takes it "almost 5x a week" for the past 2 months) 1, 2
• The 10-year history of episodic migraine (3-4 times monthly) that recently transformed to near-daily headaches is the classic progression pattern 1

Other Differentials to Consider (but less likely):

• Tension-type headache: Ruled out by unilateral, throbbing quality and associated nausea/photophobia 2
• Secondary headache disorders: No red flags present (no fever, no focal neurological deficits, age <50, gradual onset, normal neurological exam) 2, 3
• Giant cell arteritis: Age <50 years excludes this 2
• Intracranial pathology: No progressive worsening over years, no awakening from sleep, no Valsalva aggravation 2, 3

Neuroimaging Decision

Neuroimaging is NOT indicated for this patient. 2, 3

Rationale Against Neuroimaging:

• No red flags present: No recent head trauma, no new neurological symptoms/signs, age <50, no thunderclap onset, no fever/neck stiffness, no altered consciousness, normal neurological examination 2, 3, 4
• Classic migraine pattern: 10-year history with typical migraine features that evolved to chronic migraine—this is an expected natural history 1
• Normal neurological examination: Cranial nerves intact, normal motor/sensory/cerebellar function, no papilledema 2

When Neuroimaging WOULD Be Indicated:

• New-onset headache after age 50 2, 3
• Atypical aura or persistent neurological deficits 5, 2
• Progressive worsening over weeks (not months/years) 3, 4
• Headache awakening from sleep or brought on by Valsalva/cough 2, 3
• Any abnormal neurological examination findings 2, 4

Management Plan

Step 1: Address Medication-Overuse Headache (CRITICAL FIRST STEP)

Immediate withdrawal of paracetamol is mandatory—this is the most important intervention. 1

• Explain to the patient: Her daily paracetamol use is perpetuating and worsening her headaches 1
• Abrupt discontinuation: Stop paracetamol completely (no tapering needed for non-opioid analgesics) 1
• Warn about withdrawal period: Headaches may temporarily worsen for 2-10 days before improvement begins 1
• Bridge therapy: Consider short course of prochlorperazine or metoclopramide for severe withdrawal symptoms 1, 6

Step 2: Initiate Prophylactic Therapy (START IMMEDIATELY)

Prophylactic treatment is mandatory for chronic migraine—this is not optional. 1, 2

First-Line Prophylactic Options:

• Topiramate: The ONLY medication with proven efficacy in randomized controlled trials specifically for chronic migraine 1

  • Start 25 mg at bedtime, titrate by 25 mg weekly to target dose 100 mg daily (50 mg twice daily) 1
  • Warn about paresthesias, cognitive slowing, weight loss, kidney stones 1

• Alternative first-line agents (evidence from episodic migraine, commonly used for chronic migraine):

  • Amitriptyline 10-75 mg at bedtime (useful if comorbid depression/insomnia) 1, 7
  • Propranolol 80-240 mg daily (avoid in smokers with potential reactive airway disease) 8, 7
  • Valproate 500-1000 mg daily (AVOID in women of childbearing age—see contraception discussion below) 1

Step 3: Optimize Acute Treatment (For Breakthrough Attacks)

Limit acute medication use to <10 days per month to prevent recurrence of medication-overuse headache. 1, 2

For Moderate-to-Severe Attacks:

• Triptans are first-line: Sumatriptan 50-100 mg, rizatriptan 10 mg, or eletriptan 40 mg 1, 6
• Combination therapy: NSAID (naproxen 500 mg) + triptan is more effective than either alone 6
• Antiemetic: Metoclopramide 10 mg or prochlorperazine 10 mg for nausea 1, 6

For Mild-to-Moderate Attacks:

• NSAIDs alone: Ibuprofen 400-800 mg, naproxen sodium 550 mg, or diclofenac potassium 50 mg 1, 6
• Avoid paracetamol: Given her history of medication overuse 1

Critical Medication Rules:

• Maximum 2 days per week for triptan use 1, 6
• Maximum 10 days per month for any acute medication 1, 2
• Implement headache diary: Track frequency to prevent medication overuse recurrence 1, 2

Step 4: Identify and Manage Triggers

• Smoking cessation: She is a current smoker—this is a modifiable risk factor and contraindication to ergot derivatives 1, 7
• Regular sleep schedule: Irregular sleep is a common trigger 1
• Stress management: Teaching profession is high-stress; consider biofeedback or relaxation techniques 8, 7
• Regular meals: Avoid fasting 1
• Limit caffeine: Excessive caffeine can contribute to medication-overuse headache 1

Step 5: Follow-Up Schedule

• 2 weeks: Assess medication withdrawal symptoms and tolerability of prophylactic medication 1
• 4-8 weeks: Evaluate prophylactic efficacy (expect 50% reduction in headache days) 1
• 3 months: If inadequate response, consider dose adjustment or alternative prophylactic agent 1
• Neurology referral: If first-line prophylactic fails or diagnosis remains uncertain 2

Contraception Counseling

Combined hormonal contraceptives (pills, patches, rings) are CONTRAINDICATED in this patient. 1

Contraindication Rationale:

• Migraine without aura + smoking: Combined hormonal contraceptives increase stroke risk in women with migraine, especially smokers 1
• Age >35 + smoking: Additional cardiovascular risk factor 1
• Even if she quits smoking, migraine without aura at age 30+ warrants caution with estrogen-containing contraceptives 1

Safe Contraceptive Options:

• Progestin-only methods (SAFE and RECOMMENDED):

  • Progestin-only pills (desogestrel 75 mcg daily) 1
  • Depot medroxyprogesterone acetate injection (every 3 months) 1
  • Etonogestrel implant (3-year duration) 1
  • Levonorgestrel IUD (5-year duration) 1

• Non-hormonal methods (SAFE):

  • Copper IUD (10-year duration) 1
  • Barrier methods (condoms, diaphragm) 1
  • Permanent sterilization (if family complete) 1

Critical Counseling Points:

• Avoid valproate if pregnancy possible: Valproate is teratogenic and should NOT be used in women of childbearing potential unless highly effective contraception is ensured 1
• If she chooses valproate for prophylaxis: Must use highly effective contraception (IUD or implant preferred) and sign informed consent regarding teratogenicity 1
• Topiramate is safer: Also has some teratogenic risk but less severe than valproate; still requires contraception 1

Common Pitfall to Avoid:

• Do NOT prescribe combined oral contraceptives to any woman with migraine who smokes or is >35 years old—this significantly increases stroke risk 1