Event 2: Joe's Diagnosis and Treatmet

Joe's Co-Occurring Conditions

Joe’s history and clinical evaluation suggest multiple co-occurring conditions.

  • History of intermittent migraine headaches
  • Transformed migraine
  • Medication overuse headache
  • Myofascial neck pain

Medication Overuse Headache

Medication Overuse Headache (MOH) results from excessive use of analgesics

  • Secondary headache disorder
  • Analgesic use >2-3 days per month
  • Underlying diagnosis of migraine or tension-type headache
  • Preventive medications may be ineffective

Pharmacist's Role

Pharmacists play an important role in managing medication overuse headaches.

  • Often first to recognized MOH
  • Can work with healthcare team to develop tapering/monitoring plans
  • Can educate patients about proper use of analgesics and when to seek medical attention

Multipronged Treatment Plan

A multipronged treatment plan is the best approach to managing chronic headache pain.

  • Behavior modification
  • Discontinuation of analgesics
  • Preventive medications
  • Migraine-specific abortive medication

Treatment Plan

Dr. Bernstein explains to Joe various treatment options.

Preventive Medications

Preventive medications may be appropriate for some patients with frequent headache attacks.


  • Frequent attacks (1-2 per week)
  • Disability with attacks
  • Poor response to acute meds
  • Contraindications to abortive meds


  • Co-existing medical conditions
  • Concurrent medications
  • Side effects
  • Contraindications

Pharmacological Treatments

There are several evidence-based pharmacological treatments for migraine headache.

Pharmacological Treatments for Migraine
Medication Adverse Effects Limitations


  • propranolol
  • timolol
Lethargy; depression; exercise intolerance depression; asthma; low blood pressure; Raynaud's syndrome


  • topiramate
  • valproate

tingling; weight loss (topiramate)

weight gain; hair loss (valproate)

kidney stones (topiramate)

birth defects (valproate)


  • venlafaxine
  • amitriptyline
  • nortriptyline
weight gain; sleepiness; dry mouth serotonin syndrome; increased risk for anticholinergic effects in older adults (amitriptyline, nortriptyline); QT interval prolongation (venlafaxine)

CGRP Antibodies

  • erenumab
  • fremanezumab
  • galcnezumab
constipation; muscle spasms or cramps hypersensitivity; high cost
Onabotulinum toxin A Spasticity; cervical dystonia; weakness; drooping forehead hypersensitiivty; myasthenia gravis; Only approved for chronic migraine

Start low and go slow evidence-based pharmacological treatments for migraine headache.

Medicinal Herbs and Vitamins

Various medicinal herbs and vitamins have been tried for migraine prevention.

  • Riboflavin
  • Magnesium Citrate
  • Coenzyme Q10

Abortive Medications for Treating Migraine Headaches

There are several types of abortive medications for treating migraine headaches.


  • diclofenac
  • ibuprofen
  • naproxen
  • acetaminophen


Mild to moderate headache intensity used 10-15 days month; preventative for menstrual pain.

Adverse Effects

Stomach upset, bleeding, kidney or liver damage.


  • sumatriptan
  • rizatriptan
  • eletriptan
  • zolmitriptan
  • almotriptan
  • naratriptan
  • frovatriptan


Moderate to severe intensity.


Cardiovascular disease, cerebrovascular disease, uncontrolled hypertension.

Combination Drugs

  • sumatriptan + naproxen
  • aspirin + acetaminophen + caffeine (limit to 5 or fewer days/month)


Refractory headaches.

Adverse Effects

Stomach upset, bleeding, kidney or liver damage, medication overuse headache.



Refractory headaches.

Adverse Effects

Stomach upset, bleeding, kidney or liver damage.

Healthy Lifestyle

Maintaining a healthy lifestyle can help protect against headache vulnerability.

  • Sleep
  • Exercise
  • Meals and hydration
  • Stress reduction

Multimodal Approach

A multimodal approach should be introduced early in headache treatment.

Neck Pain

Joe’s physician recommends further evaluation of his neck pain.

Headache Diaries

Headache diaries can help guide treatment.

  • Frequency and severity of headaches over time
  • Triggers
  • Headache characteristics
  • Frequency of medication use
  • Exercise
  • Response to medication or therapy over time
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