What is the likely diagnosis and recommended management for a 22‑year‑old woman with a month of daily, band‑like headaches, a history of occasional migraine, who frequently uses ibuprofen and is taking fluoxetine, intermittent propranolol, montelukast, cetirizine, and fluticasone?

Chronic Tension‑Type Headache with Probable Medication‑Overuse Headache

Likely Diagnosis

This patient has chronic tension‑type headache (daily band‑like headache for 30 days) complicated by medication‑overuse headache from frequent ibuprofen use, with a background history of episodic migraine. The "cap on the head" description is classic for tension‑type headache, and the 30‑day continuous pattern without a headache‑free day meets criteria for chronic daily headache. 1 The frequent ibuprofen use—even though she reports it helps "not all days"—has likely created a medication‑overuse headache cycle that perpetuates the daily pattern. 1, 2

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Immediate Management: Medication Withdrawal

The first and most critical step is complete cessation of ibuprofen, because any NSAID use ≥15 days per month causes medication‑overuse headache and paradoxically increases headache frequency. 1, 2, 3

• Abrupt discontinuation is recommended over gradual taper; the evidence does not support slow weaning. 1
• Warn the patient that headache intensity may temporarily worsen for 2–10 days during the withdrawal period. 1
• Do not substitute another acute medication (e.g., acetaminophen, triptans) during withdrawal, as this merely transfers the overuse to a different agent. 1
• The withdrawal phase typically lasts 2–4 weeks, after which the baseline headache pattern becomes apparent and allows accurate assessment of preventive therapy efficacy. 1

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Initiate Preventive Therapy Immediately

Preventive therapy must be started concurrently with medication withdrawal, because this patient meets multiple criteria: daily headaches for 30 days, acute medication use exceeding 2 days per week, and a history of increasing migraine frequency. 1, 4, 5

First‑Line Preventive Options

Amitriptyline 30–150 mg/day is the optimal first choice for this patient because she is already on fluoxetine (suggesting possible mood comorbidity) and has a mixed pattern of tension‑type headache with occasional migraine—a scenario where amitriptyline demonstrates superior efficacy. 1, 4, 5, 6

• Start at 10–25 mg at bedtime and titrate slowly every 1–2 weeks to a target dose of 50–75 mg (or higher if tolerated, up to 150 mg). 4, 5
• Allow 2–3 months at the target dose before judging efficacy. 4, 5
• Common side effects include dry mouth, sedation, and weight gain; taking the dose at bedtime minimizes daytime sedation. 4

Alternative first‑line option: Topiramate 50–100 mg/day (typically 50 mg twice daily) is the only oral preventive with robust RCT evidence for chronic migraine and should be considered if the patient has obesity or if amitriptyline is poorly tolerated. 1, 4, 5

• Start at 25 mg at bedtime and increase by 25 mg weekly to a target of 50 mg twice daily. 4, 5
• Topiramate causes weight loss, which may be beneficial if obesity is present. 4
• Common side effects include paresthesias, cognitive slowing, and kidney stones. 4, 5

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Post‑Withdrawal Acute Medication Limits

Once medication‑overuse headache resolves (typically 2–4 weeks after ibuprofen discontinuation), acute treatment should be reserved for the most severe, disabling attacks and strictly limited to ≤2 days per week (≤10 days per month). 1, 4, 2, 3

• For tension‑type breakthrough headaches: Naproxen 500 mg (preferred over ibuprofen due to longer half‑life) or acetaminophen 1000 mg, limited to ≤2 days per week. 1, 4
• For migraine breakthrough attacks: Sumatriptan 50–100 mg plus naproxen 500 mg (combination therapy is superior to either agent alone), limited to ≤2 days per week. 1, 4
• The 2‑days‑per‑week limit is non‑negotiable and applies to all acute agents to prevent recurrence of medication‑overuse headache. 1, 4, 2

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Address Modifiable Risk Factors

• Screen for and treat obstructive sleep apnea, as it perpetuates chronic migraine. 4
• Evaluate for depression and anxiety (she is already on fluoxetine and propranolol "for anxiety"), as psychiatric comorbidities worsen headache outcomes. 4
• Assess caffeine intake and limit to ≤200 mg/day (approximately two cups of coffee) consumed consistently before noon to reduce caffeine‑withdrawal headache risk. 1
• Stress‑management interventions (cognitive‑behavioral therapy, biofeedback, relaxation training) can reduce reliance on acute medications. 4, 5, 6

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Expected Timeline and Outcomes

• Withdrawal phase (2–10 days): Transient worsening of headache intensity. 1
• Post‑withdrawal phase (2–4 weeks): Baseline headache pattern becomes apparent, allowing accurate assessment of preventive efficacy. 1
• Preventive therapy efficacy (2–3 months): Gradual improvement with the goal of ≥50% reduction in headache days and restoration of responsiveness to acute therapies. 1, 4, 5

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Critical Pitfalls to Avoid

• Continuing daily ibuprofen use "because it works" perpetuates medication‑overuse headache and guarantees treatment failure. 1, 2, 3
• Substituting opioids or butalbital compounds as rescue medications is contraindicated due to limited efficacy, high risk of dependence, and potential for rebound headaches. 1, 4
• Delaying preventive therapy while trialing multiple acute strategies undermines timely control of chronic headache. 1, 4
• Abandoning preventive therapy prematurely (before 2–3 months at target dose) is a common error; oral preventives require adequate trial duration. 4, 5

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When to Escalate or Refer

• If amitriptyline and topiramate both fail after adequate trials (2–3 months each at target dose), consider third‑line options: CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab) or onabotulinumtoxinA (Botox) for chronic migraine. 1, 4
• Refer to a headache specialist if the diagnosis is uncertain, all treatments have failed, or complications arise. 4