THE CASE: The patient—a 25-year-old white woman employed as a fourth-grade teacher—presented with left-sided, throbbing headaches that had gradually increased in severity and frequency.
Her headaches began at age 13 with menarche. These headaches, which occurred once or twice a month, were associated with photophobia, phonophobia, and nausea, and usually lasted 8 to 12 hours. They gradually progressed in severity (from mild/moderate to moderate/severe) and frequency (to 2 or 3 per week). The headaches affected the patient's job performance and attendance, and she complained of fatigue, lack of sleep, and difficulty in concentrating. She also reported increasing stress in her home life: after her husband lost his job a year earlier, she had been the sole support of her family, including her 2 young children.
The patient had been taking aspirin/butalbital/caffeine tablets for her headaches. She increased the dosage to obtain pain relief, but nausea and/or heartburn developed as a result. She occasionally resorted to the emergency department, where she received meperidine. She had previously treated her headaches with acetaminophen/aspirin/ caffeine tablets and, before that, with ibuprofen and acetaminophen.
This patient was 5 ft 5 ½ in tall and weighed 125 lb. Results of the neurologic examination were normal. Her heart rate was 78 beats per minute and regular, and her blood pressure was 110/74 mm Hg. Her chest was clear, and she appeared well nourished and otherwise healthy. However, she exhibited signs of depression.
Laboratory test results (including complete blood cell count, blood chemistry, and levels of thyroid-stimulating hormone) were normal, as was an MRI scan of the brain. The patient's Beck depression scale indicated moderate depression.
The diagnosis was migraine headaches, depression, and overuse of caffeine-containing analgesics.
She was counseled to discontinue caffeine-containing medications, to eliminate caffeinated foods and drinks from her diet, to establish consistent daily sleeping and eating patterns, and to increase her daily physical activity. To help wean her from caffeine-containing analgesics and foods, and to assuage potential withdrawal symptoms, bridge therapy with tapering doses of a corticosteroid was started. For pain relief, the patient also took 500 mg of naproxen twice daily for 1 month. Amitriptyline, 10 mg/d, and sertraline, 50 mg/d, were prescribed for her depression. For acute-migraine treatment, almotriptan, 12.5 mg, was to be taken at the first sign of a headache; the dose could be repeated once in 2 hours if the headache did not resolve, for up to 4 doses per week.
1. Dodick DW. Acute and prophylactic management of migraine. Clin Cornerstone. 2001;4:36-52.
2. National Headache Foundation. Diet and headache. Available at: www. headaches.org/
consumer/topicsheets/diet_headache.html. Accessed February 21, 2006.
3. Shechter AL, Lipton RB, Silberstein SD. Migraine comorbidity. In: Silberstein SD, Lipton RB, Dalessio DJ, eds. Wolff's Headache and Other Head Pain. New York: Oxford University Press; 2001:108-118.
4. Punay NC, Couch JR. Antidepressants in the treatment of migraine headache. Curr Pain Headache Rep. 2003;7:51-54.
5. Silberstein SD. Practice parameter: evidence-based guidelines for migraine headache (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2000;55:754-762.
6. Ferrari MD, Goadsby PJ, Roon KI, Lipton RB. Triptans (serotonin 5-HT1B/D agonists) in migraine: detailed results and methods of a meta-analysis of 53 trials. Cephalalgia. 2002;22:633-658.
7. Burstein R, Cutrer MF, Yarnitsky D. The development of cutaneous allodynia during a migraine attack: clinical evidence for the sequential recruitment of spinal and supraspinal nociceptive neurons in migraine. Brain. 2000;123(pt 8):1703-1709.
8. Burstein R, Jakubowski M. Analgesic triptan action in an animal model of in-tracranial pain: a race against the development of central sensitization. Ann Neurol. 2004;55:27-36.
9. Cady RK, Sheftell F, Lipton RB, et al. Effect of early intervention with sumatriptan on migraine pain: retrospective analyses of data from three clinical trials. Clin Ther. 2000;22:1035-1048.
10. Pascual J, Cabarrocas X. Within-patient early versus delayed treatment of migraine attacks with almotriptan: the sooner the better. Headache. 2002;42:28-31.
11. Mathew NT. Early intervention with almotriptan improves sustained pain-free response in acute migraine. Headache. 2003;43:1075-1079.
12. Hu XH, Raskin NH, Cowan R, et al; United States Migraine Study Protocol (USMSP) Group. Treatment of migraine with rizatriptan: when to take the medication. Headache. 2002;42:16-20.
13. Schoenen J. When should triptans be taken during a migraine attack? CNS Drugs. 2001;15:583-587.
14. Pascual J. Clinical benefits of early triptan therapy for migraine. Headache. 2002;42(suppl 1):S10-S17.