What is the best course of treatment for a patient with chronic headaches and foot pain, who has a history of significant ibuprofen use and is currently taking citalopram (Selective Serotonin Reuptake Inhibitor (SSRI)) for anxiety?

Comprehensive Management of Chronic Headaches with Foot Pain in a Patient on Citalopram

Immediate Priority: Rule Out Medication Overuse Headache

Given the 6-7 month history of chronic headaches and significant prior ibuprofen use, medication overuse headache (MOH) must be ruled out first, as this is the most common cause of chronic daily headache and will not respond to any treatment until the overused medication is withdrawn. 1

• Ask specifically: "Were you taking ibuprofen or any pain medication more than 2 days per week for these headaches?" 1, 2
• MOH develops when acute headache medications are used on 10 or more days per month (for NSAIDs) or 15 or more days per month (for simple analgesics) for longer than 3 months 3
• If MOH is present, abrupt withdrawal of ibuprofen is the necessary and only remedy 1
• Educate the patient that headaches will worsen for 2-10 days before improvement occurs 1

Classify the Primary Headache Disorder

After ruling out MOH, determine if this represents chronic migraine (≥15 headache days per month for >3 months, with ≥8 days having migraine features) versus chronic tension-type headache. 1

• Ask: "Do you feel like you have a headache of some type on 15 or more days per month?" 1
• Assess for migraine features: throbbing quality, nausea, photophobia, phonophobia, worsening with activity 1
• The normal CT scan appropriately ruled out secondary causes 1
• Have the patient maintain a headache diary to accurately track frequency and characteristics 1

Initiate Prophylactic Treatment for Chronic Headache

Every patient with chronic headache (≥15 days per month) requires prophylactic therapy, not just acute treatment. 1

First-Line Prophylactic Options:

For this patient already on citalopram (SSRI) for anxiety, amitriptyline 30-150 mg/day at bedtime is the optimal first choice because it treats both chronic headache and comorbid anxiety/depression with a single agent, avoiding polypharmacy. 1, 4

• Start amitriptyline 10-25 mg at bedtime and titrate slowly by 10-25 mg every 1-2 weeks 1
• Target dose is typically 50-75 mg for headache prevention 1
• Critical caveat: Monitor for serotonin syndrome when combining with citalopram, though risk is low with amitriptyline 4
• Allow 2-3 months for full therapeutic effect 1

Alternative first-line option if amitriptyline is not tolerated: Topiramate 25-100 mg/day is the only medication with proven efficacy in randomized controlled trials specifically for chronic migraine. 1

• Start 25 mg at bedtime, increase by 25 mg weekly to target dose of 100 mg daily 1
• Particularly beneficial if patient has comorbid obesity (causes weight loss) 1
• Common side effects include paresthesias, cognitive slowing, and kidney stones 1

Acute Treatment Strategy

Limit acute headache medication to no more than 2 days per week to prevent recurrence of MOH. 1, 2

For moderate-to-severe headache days:

• Sumatriptan 50-100 mg PLUS naproxen sodium 500 mg is superior to either agent alone 2
• This combination provides 130 more patients per 1000 achieving sustained pain relief at 48 hours 2

For mild-to-moderate headache days:

• Naproxen sodium 500-825 mg at onset (maximum 1.5 g/day) 2
• Can add metoclopramide 10 mg for synergistic analgesia and nausea 2

Address the Foot Pain Separately

The bilateral foot pain with deep aching and cold soles requires evaluation for erythromelalgia, peripheral neuropathy, or vascular insufficiency—this is NOT related to the headache disorder. 1

Diagnostic workup for foot pain:

• Check hemoglobin A1c, vitamin B12, TSH, comprehensive metabolic panel to rule out metabolic neuropathy 1
• Assess pedal pulses and ankle-brachial index if vascular etiology suspected 1
• Consider referral to neurology if neuropathy confirmed 1

If erythromelalgia is suspected (burning pain with cold extremities):

• Trial of topical lidocaine 5% patches applied to affected areas 1
• Gabapentin 300 mg at bedtime, titrating up to 2400 mg daily divided into 3 doses 1
• Important: Gabapentin also has modest evidence for migraine prevention, providing dual benefit 1

Psychiatric Comorbidity Management

Continue citalopram for anxiety, as psychiatric comorbidities worsen migraine prognosis and increase risk of chronification. 1, 4

• SSRIs like citalopram are appropriate for both depression and anxiety in migraine patients 4
• Screen for depression using MEASLES acronym: Mood, Energy, Appetite, Sleep, Libido, Enjoyments, Suicidal ideation 5
• Consider cognitive behavioral therapy as adjunct, which has good evidence for both anxiety and chronic pain 1, 4

Non-Pharmacologic Interventions

Implement behavioral strategies as part of comprehensive management: 1

• Relaxation training and progressive muscle relaxation 1
• Biofeedback therapy 1
• Regular aerobic exercise 40 minutes three times weekly (as effective as topiramate in trials) 1
• Identify and modify triggers: sleep hygiene, caffeine intake, stress management 1

Follow-Up and Monitoring

• Reassess in 4-6 weeks to evaluate prophylactic medication response 1
• Continue headache diary to track frequency reduction 1
• If no improvement after 2-3 months of optimized prophylactic therapy, refer to neurology/headache specialist 1
• Red flags requiring immediate neurologist referral: new focal neurologic findings, persistent aura, motor weakness, or thunderclap headache 1, 6

Critical Pitfalls to Avoid

• Never prescribe opioids for chronic headache—they cause dependency, medication overuse headache, and loss of efficacy 2, 7
• Do not allow escalation of acute medication frequency; transition to preventive therapy instead 1, 2
• Do not use beta-blockers (propranolol, timolol) as they may worsen peripheral vascular symptoms causing the foot pain 1
• Avoid flunarizine if available, as it can cause depression and extrapyramidal symptoms 1