New Clinic Patient Consultation

Diagnosis

Primary diagnosis: Chronic migraine without aura. Differential diagnosis: Medication-overuse headache (secondary to frequent triptan and simple analgesic use), tension-type headache. Pertinent symptoms: 18 days/month of unilateral throbbing headache, moderate-to-severe intensity, associated photophobia, phonophobia, and nausea. No visual aura, autonomic features, or focal neurological deficits.

Plan

• Commence propranolol 40 mg PO BID for migraine prophylaxis, titrating up to 80 mg PO BID after 2 weeks as tolerated.
• Limit sumatriptan 50 mg PO PRN to a maximum of 2 days per week to prevent medication-overuse headache.
• Cease all codeine-containing analgesics immediately.
• Maintain a headache diary (tracking frequency, severity, triggers, and acute medication use).
• Lifestyle modifications: ensure regular sleep hygiene, adequate hydration (2 L/day), regular meals, and gradual reduction of caffeine intake.
• Follow-up in general neurology clinic in 3 months with headache diary.

Previous Medical History

• Episodic migraine (diagnosed age 22)
• Mild intermittent asthma ( childhood, no recent exacerbations or inhaler use in > 10 years; cleared for cautious beta-blocker trial, though alternative discussed if wheeze occurs)
• Appendicectomy (14/05/2015)
• Family history: Maternal history of migraine. No family history of intracranial aneurysm or stroke.

Medications

• Sumatriptan (Imigran®) 50 mg PO PRN (currently taking ~12 days/month)
• Co-codamol 8/500 mg PO PRN (currently taking ~15 days/month)
• Ibuprofen (Nurofen®) 400 mg PO PRN
• Magnesium citrate 400 mg PO OD (OTC supplement)
• Riboflavin (Vitamin B2) 400 mg PO OD (OTC supplement)
• Allergies: Penicillin (maculopapular rash)

Ms Sarah Jenkins (DOB: 12/08/1988, NHS: 482 910 3847) attended the neurology outpatient clinic today referred by her GP regarding an escalation in headache frequency over the past 6 months. She has a background of episodic migraines since her early twenties, previously well-controlled. Recently, following a period of occupational stress, her headaches have increased to approximately 18 days per month, with at least 10 days fulfilling criteria for migraine. The pain is typically right-sided, frontotemporal, and throbbing, lasting 12–24 hours if untreated. It is accompanied by nausea, photophobia, and phonophobia, forcing her to lie in a dark room. She denies visual aura, vertigo, diplopia, weakness, or sensory changes. There are no red flag features such as thunderclap onset, positional exacerbation, Valsalva worsening, or systemic symptoms (fever, weight loss). To cope with work, she has been taking sumatriptan and OTC co-codamol frequently, which now provide only partial, temporary relief. She drinks 4 cups of caffeinated coffee daily, sleeps poorly, and does not smoke or consume alcohol.

Examination

BP 118/74 mmHg, HR 68 bpm regular. Cranial nerves II–XII intact; fundoscopy showed crisp optic discs bilaterally with spontaneous venous pulsation present. Visual fields full to confrontation, pupils equal and reactive to light, extraocular movements full with no nystagmus. Upper and lower limb neurological examination revealed normal tone, full power (5/5 MRC scale throughout), symmetrical reflexes (2+), flexor plantar responses bilaterally, and intact sensation to light touch and pinprick. Coordination (finger-nose and heel-shin) and gait (including tandem gait) were normal. No cervical paraspinal tenderness or meningism.

Summary

I explained to Ms Jenkins that her clinical presentation and normal neurological examination are consistent with chronic migraine, complicated by a secondary medication-overuse headache driven by the frequent intake of sumatriptan and co-codamol. We discussed how frequent use of acute pain relief paradoxically lowers the brain's threshold for headache generation. I advised her to stop taking co-codamol completely and to strictly restrict sumatriptan use to no more than two days per week, warning her that her headaches may transiently worsen for 1–2 weeks during this withdrawal phase. To reduce the baseline frequency and severity of her migraines, we agreed to start a preventative medication, propranolol 40 mg twice daily, increasing to 80 mg twice daily after two weeks if well tolerated; given her distant history of childhood asthma, I counselled her to stop the medication and contact us or her GP if she experiences any shortness of breath or wheezing, in which case we would switch to candesartan or amitriptyline. Finally, I encouraged her to slowly cut down on caffeine, maintain regular hydration and sleep patterns, and keep a detailed headache diary to review at our follow-up appointment in three months' time.