Migraine

Impression: Chronic migraine with visual aura and secondary medication overuse headache.

Past Medical History:

1. Mild intermittent asthma
2. Endometriosis

Current Medications:

1. Salbutamol 100 mcg/actuation inhaler 2 puffs INH PRN
2. Co-codamol 8/500 mg 2 tablets PO QID PRN
3. Sumatriptan 50 mg PO PRN

Management Plan

1. Cease all codeine-containing analgesia immediately to address medication overuse headache.
2. Commence candesartan 4 mg PO OD for migraine prophylaxis, titrating up to 8 mg PO BD as tolerated.
3. Optimise acute therapy with sumatriptan 50 mg PO and metoclopramide 10 mg PO at headache onset, limited to a maximum of 2 days per week.
4. Maintain a headache diary and discharge back to GP care for review in 3 months.

Migraine Advice for the Patient and GP

1. Self-education
   • www.migrainetrust.org website, including the sections on migraine triggers and coping with migraine
2. Relaxation and mindfulness
   • Self-referral to psychology through the IAPT NHS website
   • Headspace app
   • Online CBT
3. Acute therapies
   • Ibuprofen 800 mg or aspirin 900 mg with domperidone 20 mg or metoclopramide 10 mg; consider this unsuccessful only when it has failed on fewer than one-third of occasions.
   • If needed, change to a triptan taken with an anti-emetic, metoclopramide, trying each triptan sequentially in this order:
     • sumatriptan 50 mg o.d. or 20 mg nasal spray
     • almotriptan 12.5 mg o.d.
     • rizatriptan 10 mg tablets or wafers o.d.
     • zolmitriptan 2.5 mg, increasing to 5 mg for later attacks when 2.5 mg does not provide satisfactory relief
     • eletriptan 40 mg o.d.
   • If this is ineffective, use naproxen 500 mg with the most effective triptan and an anti-emetic.
   • Principle: Try each individual drug on at least three occasions to determine whether it helps; regard it as unsuccessful only when it fails on ≥2 of 3 occasions.
4. Migraine prophylaxis
   • To reduce migraine frequency and impact, the GP may consider one of the following preventive medicines:
     • Amitriptyline, beginning at 10 mg nocte and increasing weekly towards 50 mg nocte; maximum 75 mg nocte
     • Candesartan 4 mg daily, increasing towards 8 mg bd
   • Continue any preventive treatment for 6 weeks at the maximum dose, or the maximum tolerated dose, before reviewing the headache diary and assessing effectiveness.

Thank you for referring this 34-year-old right-handed female who attended the neurology clinic. She is a secondary school teacher who has experienced episodic headaches since her late teens, which have progressively worsened over the past 18 months to approximately 18 headache days per month, with 10 of these being severe disabling attacks.

Her typical severe attack begins with a 2-hour prodrome of neck stiffness and yawning, followed by a 20-minute visual aura of binocular fortification spectra. The headache is unilateral, frontotemporal, and throbbing in quality, lasting up to 48 hours if untreated, and is accompanied by marked photophobia, phonophobia, kinesophobia, anorexia, and nausea with occasional vomiting; identified triggers include menstruation, sleep deprivation, and work-related stress.

The frequent headaches have significantly impacted her quality of life, resulting in 12 days of sickness absence from teaching over the past 6 months and forcing her to withdraw from weekend social activities.

Her husband, who attended the clinic today, noted that she becomes visibly pale and exhausted prior to an attack and requires a completely dark, quiet room for up to two days until the episode resolves.

Regarding previous treatments, she currently takes sumatriptan 50 mg PO with partial relief, alongside co-codamol 8/500 mg on up to 15 days per month, which likely contributes to a medication overuse component; she previously trialled amitriptyline 10 mg PO nocte for two weeks but discontinued it due to morning somnolence.

There is a positive family history of migraine in her mother and maternal aunt, with no other history of neurological disorders.

She lives with her husband and holds a full UK driving licence; she is a lifelong non-smoker, drinks 2 units of alcohol per week, and denies any recreational drug use, though she consumes four cups of caffeinated coffee daily.

Routine blood tests, including FBC, U&Es, CRP, and TFTs performed last month were unremarkable, and a non-contrast CT head arranged via primary care on 12/01/2026 was entirely normal.

Neurological Examination

On examination today, her blood pressure was 118/74 mmHg and her pulse was 68 bpm. Cranial nerve examination was entirely normal, with bilateral sharp optic discs and preserved spontaneous venous pulsation on fundoscopy. Tone, power, coordination, reflexes, and sensation in both the upper and lower limbs were completely normal, with plantars downgoing bilaterally and a normal gait.

Summary and Recommendation

The clinical history and normal neurological examination are characteristic of chronic migraine with aura, complicated by a secondary medication overuse headache from frequent opioid analgesia and caffeine intake. Given her history of asthma, beta-blockers are contraindicated; I have therefore advised immediate cessation of co-codamol, gradual caffeine reduction, and initiation of candesartan for migraine prophylaxis alongside optimised acute triptan therapy.