What is the best course of management for a 42-year-old patient with a history of ischemic heart disease, presenting with persistent headaches, photophobia, and occasional nausea, despite current medication regimen?

Management of Persistent Headache in a 42-Year-Old with Ischemic Heart Disease

This patient requires immediate evaluation for medication overuse headache (MOH) and initiation of migraine prophylaxis with topiramate, while simultaneously ruling out cardiac cephalgia given the history of ischemic heart disease and recent acute presentation. 1

Critical Diagnostic Considerations

Rule Out Cardiac Cephalgia First

• Cardiac ischemia can present as isolated headache, particularly in patients with established coronary artery disease and cardiovascular risk factors 2, 3
• The patient's recent presentation with left-sided chest pain, facial/arm tingling, and subsequent persistent severe headache warrants consideration of ongoing cardiac ischemia as the headache etiology 2
• Exertional headaches in patients with IHD should trigger immediate cardiac workup, as chronic total occlusions and acute coronary syndromes can manifest solely as headache 2
• While CT angiography showed no acute abnormality, the patient has documented mild non-obstructive atherosclerosis and should undergo stress testing or functional cardiac assessment to exclude ongoing ischemia as the headache trigger 4

Assess for Medication Overuse Headache

• This patient meets criteria for MOH: headache on ≥15 days/month with regular overuse of paracetamol and Voltaren (NSAIDs) for >3 months 4, 1
• The American Academy of Neurology states that 68% of chronic daily headache patients exhibit migrainous features (photophobia, nausea, severe pain), which this patient demonstrates 1
• NSAIDs and acetaminophen can be stopped abruptly or weaned within one month without requiring gradual taper 1

Probable Chronic Migraine Diagnosis

• The patient meets criteria for chronic migraine: severe constant headache (10/10 severity), photophobia, occasional nausea, and minimal relief from current analgesics 4
• Suspect chronic migraine in persons with ≥15 headache days per month, particularly with accompanying photophobia, phonophobia, and nausea 4
• The transformation from episodic to chronic daily headache can be precipitated by uncontrolled cardiovascular risk factors and medication overuse 1

Immediate Management Algorithm

Step 1: Cardiac Evaluation (Within 72 Hours)

• Order stress testing (exercise ECG, stress echocardiogram, or myocardial perfusion imaging) to exclude cardiac ischemia as the primary headache etiology 4, 2
• Given the patient's IHD history and recent acute presentation, functional cardiac assessment takes priority before attributing symptoms solely to primary headache disorder 2, 3
• If stress testing reveals ischemia, refer to cardiology for revascularization consideration, as successful percutaneous intervention resolves headache in cardiac cephalgia cases 2

Step 2: Medication Withdrawal

• Immediately discontinue paracetamol and Voltaren to break the medication overuse cycle 1
• Counsel the patient that headache may temporarily worsen for 2-10 days during withdrawal before improvement occurs 4, 1
• Non-opioid analgesics can be stopped abruptly without requiring gradual taper 1

Step 3: Initiate Migraine Prophylaxis

• Start topiramate 25 mg daily, titrating to target dose of 50 mg twice daily over 4-6 weeks 1
• Topiramate is first-line for migraine prophylaxis and offers dual benefits of headache prevention and potential weight loss (relevant given cardiovascular risk factors) 1
• Counsel about side effects: cognitive slowing, paresthesias, depression risk, reduced oral contraceptive efficacy, and teratogenic potential 1
• Expected outcome: 50% reduction in headache frequency and severity within 2-3 months 1

Step 4: Acute Headache Management During Transition

• For breakthrough severe headaches during medication withdrawal and prophylaxis initiation, use ketorolac 60 mg IM (reserved for severe attacks, unlikely to cause rebound) 4
• Alternatively, consider prochlorperazine for headache pain relief and nausea control 4
• Avoid continued use of NSAIDs, acetaminophen, or opioids to prevent perpetuating medication overuse 4

Non-Pharmacological Interventions

Lifestyle Modifications (Implement Immediately)

• Regular sleep schedule, consistent meal timing, adequate hydration, and caffeine limitation (American Heart Association recommendations) 1
• Initiate exercise program: 40 minutes three times weekly, which has equivalent efficacy to topiramate for migraine prevention 1
• Maintain headache diary to track frequency, severity, triggers, and medication use 4, 1

Cardiovascular Risk Factor Optimization

• Resume lipid-lowering therapy (statin), as the patient has documented IHD and atherosclerosis but was inappropriately discontinued from cholesterol medication 4
• Optimize blood pressure control, as uncontrolled hypertension increases migraine frequency and can transform episodic migraine into chronic daily headache 1
• Smoking cessation if applicable, given IHD history 4

Follow-Up and Monitoring

2-Week Follow-Up

• Assess medication withdrawal symptoms and tolerance of topiramate initiation 1
• Review stress testing results and adjust management if cardiac ischemia identified 4, 2
• Continue titrating topiramate toward target dose 1

2-3 Month Reassessment

• Evaluate response to prophylactic therapy at therapeutic dose 1
• Review headache diary for frequency and severity reduction (goal: 50% improvement) 1
• If refractory to two adequate trials of prophylactic medications, refer to headache specialist 1

Critical Pitfalls to Avoid

Do Not Miss Cardiac Cephalgia

• Failure to consider cardiac ischemia in older patients with IHD presenting with new-onset severe headache can delay life-saving intervention 2, 3
• The absence of chest pain does not exclude acute coronary syndrome, as headache can be the sole manifestation 2, 3
• Exertional component or pressure-like quality should heighten suspicion for cardiac etiology 2

Do Not Continue Analgesic Overuse

• Continuing paracetamol and NSAIDs will perpetuate the chronic daily headache cycle and prevent prophylactic therapy from working effectively 4, 1
• Patients must understand that stopping overused medications is essential for improvement, despite temporary worsening 1

Do Not Delay Prophylaxis

• Starting prophylactic therapy concurrent with medication withdrawal improves outcomes compared to withdrawal alone 1, 5
• Waiting to see if withdrawal alone resolves headaches delays effective treatment and prolongs disability 1

Address Cardiovascular Risk Factors

• Uncontrolled cardiovascular risk factors (hyperlipidemia, hypertension) can perpetuate chronic migraine and increase risk of cardiac events 1
• Restarting statin therapy is essential given documented IHD and atherosclerosis 4