|The patient is a 47-year-old man who began to experience frequent headaches about 6 years before he presented to a neurology clinic. The headaches rapidly progressed to become daily and almost constant. He described a sensation of dull pressure in both temples that was present on or within a few hours of awakening and that persisted for the remainder of the day. He experienced a more intense, disabling, throbbing pain in the same location once or twice a week, with photophobia and nausea, that might last 2 to 3 days. The patient took 2 to 6 over-thecounter (OTC) analgesic tablets each day—usually 200 mg of ibuprofen. These would dull but not terminate the pain.
Six months after the onset of these headaches, the patient sought care from a primary physician, who diagnosed mild hypertension (blood pressure, 140/102 mm Hg). Results of a 24-hour urinalysis for catecholamines and an MRI scan of the head were normal. The patient was referred to a neurologist, who reported that the neurologic examination was normal and that the diagnosis was tension-type headache; that doctor prescribed amitriptyline, 10 mg hs. The patient stopped taking the medication after a few weeks because of side effects, however. The primary physician thought that the hypertension was causing the headaches, and prescribed 50 mg/d of atenolol. Despite this therapy, the patient continued to experience daily headaches for the following 51/2 years.
During that 51/2-year interval, the patient returned periodically to the primary care physician; he also checked his blood pressure frequently at home. Most blood pressure recordings were normal, but elevations as high as 160/ 110 mm Hg occurred whenever he omitted the antihypertensive medication for a day or two. There was no change in the pattern of the almost constant headaches with these elevations of blood pressure. His daily consumption of analgesics continued. Five years later, nifedipine, 30 mg/d, was added to the regimen. This agent did not change the headaches, but it did reduce the blood pressure. In previous years, the patient had infrequently experienced typical episodic tension-type headaches that might start in the afternoon; these could be quickly terminated with 1 or 2 tablets of an OTC analgesic. He also experienced an occasional isolated migraine without aura. The medical history was otherwise noncontributory. The patient was unaware of any elevations of blood pressure before his initial visit to the primary physician.
He was referred to the Vanderbilt Headache Clinic with this 6-year history of almost constant headaches with superimposed migrainelike attacks for which he had used 4 to 6 analgesic tablets daily. The history was reviewed; results of his neurologic examination were normal. Blood pressure was 90/62 mm Hg in the right arm and 90/ 68 mm Hg in the left. Rebound headache was suspected.
The phenomenon of rebound headache was carefully explained to the patient. He was told that until proved otherwise, the headaches of 6 years’ duration were the result of the almost daily use of pain relief medications. He was given a list of analgesics (aspirin, acetaminophen, NSAIDs, opiates, ergotamine, triptans, and caffeine) to avoid completely. He was also told to stop the antihypertensive agents and to monitor his blood pressure frequently at home. Finally, he was asked to keep a headache calendar and to return to the clinic in 4 weeks.
After the forbidden pain relief medications were totally omitted, the patient’s headaches gradually subsided. After 3 weeks, he had the onset of 12 consecutive days of total freedom from pain. At that time, he was told to limit analgesics to 2 days per week in the future. More frequent use of analgesics might result in recurrence of the chronic daily headache and the hypertension.
During the following 5 years, the patient’s blood pressure remained normal without the antihypertensive agents, except for a single recording of 148/94 mm Hg during the fifth month. He had infrequent, brief, tension-type headaches, but no daily headaches and no migraines. He seldom used an analgesic during this 5-year interval.
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