Event 2: Physical Exam and Medication History

Upon further questioning we find out that Melissa is currently taking 2 tablets of butalbital/acetaminophen/caffeine 50-325-40 mg 2-3 days per week which slightly improves the severity of the headaches. She alternates between the following medications as needed each day of headache: acetaminophen, ibuprofen, naproxen, and sumatriptan. In total, she is treating with butalbital containing product 10 days per month, other over the counter medications 20 days per month and sumatriptan 6 days per month.

In the remote past she has tried topiramate daily for 1.5 years as a preventive medication. She does not recall effectiveness. For current aggravation of headache, she started nortriptyline 10mg at bedtime for prevention 2 weeks ago and has yet to determine if it has helped. She has tried complementary therapies including: naturopathic medicine, craniosacral therapy, chiropractic care and magnesium and melatonin supplements. She has tried avoidance of headache triggers without success. The last 2 years she has not exercised as often due to her busy schedule. She does not smoke, drink caffeine, alcohol or consume eggs, dairy or sugar.

Melissa Asks About Medication Options

Current Medications

Butalbital/Acetaminophen/Caffeine 50-325-40mg 1-2 tabs/day PO PRN HA
Nortriptyline 10mg Cap PO HS
Acetaminophen 650mg Q4-6hrs PRN HA
Ibuprofen 600mg Q4-6hrs PRN HA
Naproxen 500mg Q4-6hrs PRN HA
Sumatriptan 50mg PRN HA x1 may repeat in 2h

Test Your Knowledge

Which of the medications on Melissa’s medication list has highest risk of causing medication overuse?

Incorrect

Correct Rationale: Butalbital is a barbiturate that is used in combination analgesics used to treat headache in the United States. It has been banned in many European countries for over 15 years due to its association with medication overuse.4,19 Butalbital has been associated with a twofold increase in risk of converting from episodic to chronic migraine.19 It also may produce an increased sensitivity to pain. The American Headache Society recommends against prescribing butalbital-containing medication as the first line treatment of chronic headache. Similarly, the American Academy of Neurology states only to use butalbital-containing medication for the treatment of migraine as a last resort.20 As a barbiturate, butalbital is also habit-forming and can decrease seizure threshold if abruptly withdrawn.

Incorrect

Precision Questioning

An integral part of accurate assessment and diagnoses is to obtain the most precise medical history from the patient. This requires a specific line of questioning when it comes to headache disorders. The University of Washington Headache Clinic has developed a list of history questions that can help providers obtain the information that can lead to a prompt and accurate diagnosis.

Precision History Questions Recommended by the University of Washington Headache Clinic

How many days of ANY type of headache do you have per month?

This question makes sure that the patient is reporting all headache days per month. Sometimes patients will only report severe headache days or only migraine days.

How many headache free days do you have per month?

This is a great follow-up question to the previous question because again it is trying to tease out exactly how many total headache days and how many headache free days the patient is experiencing each month.

What happens on the days that you do not have headache and are headache free?

Again, this is clarifying how many headache free days there are and if there is anything different that occurs on those days.

How do you treat your headache? How often? With what? When?

Patients may have many different medications or regiments that they follow for different types of headaches. It is important information on how they treat ALL their headaches.

What analgesics do you take for other conditions?

Patients may forget to report the analgesics that they are taking for other pain conditions.

Clinical Pearl

It is important for providers to find non-judgmental ways to interact with patients and pursue clarifying questions to obtain the most accurate medical history. Using leading questions or a disapproving manner or tone of voice can lead the patient to underreport their headaches and medication use. This will lead to an incorrect diagnosis and ineffective treatment.

Side Note

Additional Precision questions that clarify headache history and management to date:

Have you had more than 5 headaches in your lifetime?
Where are the headaches located? Please point to the locations.
How does the headache feel, how would you describe the headache?
How long does the headache last WITHOUT treatment?
What else do you experience during the headache? Do you feel crummy or nauseated, have more sensitivity to sounds or lights?
When do you treat the headache?
What percent of relief do you experience with medications?
How many days per week, or per month do you end up treating your headache with medication?
How many days per week or month do you end up treating other pain with medication?

Clinical Pearl

Many people take medications for other types of pain (back pain, dental pain) and do not think to mention this when interviewed about medication use. Medication overuse can be easily missed when the correct questions are not asked.

Physical Exam

BP

105/71

P

RR

SpO2

98%

Ht

5'4" (1.63m)

Wt

155lb (70.31kg)

BMI

26.6kg/m2

When trying to rule out urgent secondary causes of headache it is essential to focus on the neurologic exam, including an ophthalmic and funduscopic exam. Verify that there is no ptosis, abnormal autonomic symptoms such as eye lacrimation, and abnormal extraocular movements. Assess symmetrical strength, reflexes and tandem walk.

Melissa’s physical and neurological exam is benign, which supports the diagnosis of MOH. If there are any abnormalities found on ophthalmic or neurologic exam, an alternative diagnosis must be considered.

Side Note

HEENT

Normocephalic atraumatic

Fundi:

No papilledema, normal venous pulsations.

NEURO

Mental status

Alert and oriented with normal attention, concentration, language, recent and remote memory.

Cranial nerves

Optic discs appear normal, pupils equal and reactive to light, extraocular eye movements intact, facial sensation intact to light touch, face symmetric with full facial movements, hearing intact to conversation, palate elevates symmetrically, tongue protrudes midline, sternocleidomastoid and trapezius are 5/5 bilaterally.

Motor

Bulk and tone are normal. Strength is 5/5 throughout in both upper and lower extremities.

Reflexes

2+ and symmetric throughout in both upper and lower extremities.

Sensation

Intact to light touch in both upper and lower extremities.

Coordination

Finger-to-nose intact bilaterally.

Gait

Normal gait, able to walk on heels and toes, Romberg is stable.

Movements

No tremor or abnormal movements observed.

https://youtu.be/ONRX9yGLXXM leads an exemplary video of a cranial nerve examination by Martin Samuels, MD a renowned neurologist from Harvard. It is highly recommended to watch the entirety of this video. (Please note: this is an external video link and is therefore not 508 compliant.)

Test Your Knowledge

Physical Exam Findings

Patient’s with medication overuse headache will typically have which one of the following physical exam findings:

Incorrect

Correct Rationale: The patient with MOH will generally not have any physical exam findings. It is possible that they may have a slightly elevated heart rate due to pain or anxiety. Any abnormal neurological or ophthalmic findings require further clarification based on history and potentially further work-up.

Incorrect

Most Likely Diagnoses for Melissa

When taking into consideration the ICHD-3 criteria and the H & P what are the most likely diagnoses for Melissa? (There may be more than one correct answer.)

Incorrect

Correct. Rationale: The ICHD-3 diagnostic criteria for MOH and chronic migraine align with Melissa’s symptoms. Melissa meets the diagnostic criteria for MOH because she has been experiencing 30 days of headache a month for the last 3 months and using butalbital 10 days per month and using a combination of acetaminophen, ibuprofen, naproxen, and sumatriptan approximately 20 days per month.4 She also meets the diagnostic criteria for chronic migraine because she has experienced headache > 15 days per month for > 3 months and has had migraine type symptoms on at least 8 days per month.1 Note that she can have both diagnoses together.

Incorrect

Modifiable Risk Factors

Since many of the risk factors associated with chronic migraine and MOH, such as female sex, are not modifiable, it is important to recognize those that are.

The risk of developing MOH escalates with the greater number of:

Headache days during a lifetime
Average days of analgesic medication use per month
Years of analgesic medication use
Physicians consulted
Different medications used
Headaches at baseline^17,21

Test Your Knowledge

What risk factors are identified in Melissa’s history for the development of chronic daily headache? (There may be more than one correct answer.)

Correct. Rationale: Melissa experiences 30 headache days per month, her BMI is 26.6, she is taking butalbital 10 days/month and OTC simple analgesics 20 days/month, her PSS score is 18.

Incorrect

Correct Rationale: Melissa experiences 30 headache days per month, her BMI is 26.6, she is taking butalbital 10 days/month and OTC simple analgesics 20 days/month, her PSS score is 18.

There are several risk factors associated with transformation of episodic migraine to chronic migraine, with medication overuse being an important modifiable risk factor to identify. While addressing medication overuse is essential, it is important to identify any additional risk factors. Modifiable risk factors in addition to medication overuse to screen for include caffeine consumption, stressful life events, mood and sleep disorders as well any increase in headache frequency.^17,21

Number of Headaches

The primary risk factor for progression from episodic to chronic migraine (CM) is the number of days with headache at baseline. An elevated risk for developing CM occurs in those who experienced > 3 headache days per month.^17,21 Repetitive episodes of pain can cause increase in release of CGRP and development of central sensitization.²²

Obesity

Elevated body mass index (BMI) is associated with an increase in the frequency of headache attacks. Individuals with a BMI > 30 have a 5 times greater risk of developing CM. Those with a BMI > 25 have a 3 times greater risk of CM. Obesity is associated with sensitization at the trigeminal nerves and identified as a pro-inflammatory, pro-thrombotic state. Obesity also increases CGRP levels.^17,23

Medication Overuse

As we have discussed, when opioids, NSAIDs, acetaminophen, triptans or other acute treatments are used in higher frequency by those that have pre-existing migraine, the development of CM is highly likely.^17,21

Caffeine

The only substance shown to cause withdrawal headache in placebo-controlled double-blind trials is caffeine.²² It is important to identify all sources of dietary caffeine such as coffee, tea and soft drinks. Caffeine-withdrawal headache has been reported in individuals who consume as little as 1 cup of coffee a day.²⁵

Mood Disorders

Patients with depression are over 40% more likely to develop migraine, and conversely, patients will migraine are 60% more likely to develop depression.²⁷ A recent stressful life event is an independent risk factor for CM.²⁸

Elevated Stress Response

The impact of stress on the brain and body is vast and complex and has long been connected as a risk factor for worsening migraine.^17,29 Since the 1960s it has been thought that migraine is a disorder of serotonergic transmission, causing disruption of function of the brain.³⁰ This theory has been supported by more recent electrophysiological and functional neuroimaging studies.³¹ Serotonin imbalances are thought to play a crucial role in migraine pathogenesis.³⁰

Test Your Knowledge

Factors that Worsen Headaches

Which of the following would be least important factors to consider that might lead to worsening headaches (migraine progression)?

Incorrect

Correct. Rationale: Many patients consider barometric pressure and weather changes to be contributing factors to their headaches. There is limited data that weather changes can worsening migraine, and they are not modifiable except by relocating.

Incorrect

Modifiable Risk Factors For Melissa

What approaches can you use to address some modifiable risk factors for Melissa? (Please check all that apply.)

Incorrect

Correct. Rationale: Randomized-controlled trials have proven that nutrition, exercise, stress reduction techniques, preventive therapy and alternative acute treatment options can decrease the risk of headache. The following sections provide detailed information on these modalities.

Melissa was unaware of her modifiable risk factors for headache worsening until she learned about treatment recommendations that included several modalities. Patient education about risk factors and what patients can do to promote recovery is an important part of headache treatment.