Analgesic Induced Headache

History Taking

• Chief complaint:

  • Frequent headaches.

  • Headaches increasing in frequency and severity.

  • Possible description of the headaches as a dull, generalized ache.

• History of presenting complaint:

  • Recurrent headaches for several months or years.

  • Patient may have originally had episodic migraines or tension-type headaches that have become chronic.

  • Headaches occur on more than 15 days per month.

  • Patient may describe an attempt to relieve headaches with over-the-counter analgesics or prescribed painkillers.

  • Headaches may worsen a few hours after taking analgesics or in the early morning.

• System review:

  • No abnormalities expected except related to the headaches.

  • The patient may complain of sleep disturbances due to chronic headaches.

• Past medical history:

  • History of episodic primary headaches like migraines or tension-type headaches.

  • Potential history of anxiety, depression, or other psychiatric conditions.

  • There may be a history of other chronic pain conditions.

• Drug history:

  • Prolonged and frequent use of analgesics, possibly over-the-counter drugs like aspirin, acetaminophen, or NSAIDs, or prescription drugs such as opioids or triptans.

  • Use of analgesics more than 10-15 days per month for at least three months.

  • Lack of efficacy of the analgesics over time.

• Family history:

  • Family history of migraines or other primary headache disorders can be present but not necessary for this diagnosis.

• Social history:

  • The chronic headaches may affect the patient's work, social engagements, or quality of life.

  • There might be a history of increased stress.

Physical Examination

• General examination:

  • Patient appears distressed due to pain.

  • No pallor, cyanosis, jaundice, or dehydration signs in the general inspection.

• Examination of the hands and arms:

  • No clubbing, cyanosis, or palmar erythema indicating no chronic disease.

• Examination of the face:

  • In the context of headache, may observe patient wincing, grimacing, or other signs of pain.

  • Eyes: Pupils are equal and reactive to light, no nystagmus or papilledema, indicating no increased intracranial pressure.

  • Look for anaemia

  • No nasal discharge or sinus tenderness, ruling out sinusitis as a cause for the headache.

• Examination of the neck:

  • Neck: no lymphadenopathy, no neck stiffness, and negative Kernig's sign, ruling out meningitis.

• Cardiac examination:

  • Heart sounds normal with no added sounds or murmurs.

• Respiratory examination:

  • Normal respiratory rate, pattern, and chest expansion.

  • Clear breath sounds bilaterally, no added sounds.

• Abdominal examination:

  • Abdomen soft and non-tender, no organomegaly.

• Neurological examination:

  • Normal cognitive function.

  • Cranial nerves II-XII intact.

  • Normal motor and sensory examination, ruling out a neurological cause for the headache.

  • Normal coordination and gait.

  • No signs of meningeal irritation.

Investigations

• Laboratory investigations:

  • Complete Blood Count: To rule out anemia or infection.

  • Thyroid function tests: To exclude hypothyroidism as a cause of headache.

  • Blood glucose: To exclude hypoglycemia or hyperglycemia as causes of headache.

  • Renal function tests and electrolytes: To assess for renal disease or electrolyte imbalances which may contribute to headache.

  • Liver function tests: To assess for liver disease which may contribute to headache.

  • Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP): To rule out giant cell arteritis in older patients with new-onset headache.

• Imaging investigations:

  • Brain CT scan without contrast: To rule out intracranial bleeding, mass, or stroke.

  • Brain MRI scan: To rule out demyelinating diseases, brain tumors, or other causes of headache not seen on CT scan.

• Invasive investigations:

  • Lumbar puncture: If there's a high suspicion of central nervous system infection or subarachnoid hemorrhage, despite normal imaging.

• Other tests:

  • Neurophysiological studies like EEG if seizures are suspected.

  • Visual field testing by perimetry: To exclude glaucoma or a mass lesion affecting the visual pathways.

Management

• General management:

  • Patient education: Explain the condition and the role of overused medication in maintaining the headache cycle.

  • Lifestyle modifications: Advise on regular sleep, regular meals, hydration, and stress management.

  • Encourage a headache diary: To track headache frequency, severity, triggers, and medication use.

• Medical management:

  • Withdrawal of overused medication: This should be done gradually if opioids, barbiturates, or benzodiazepines are involved due to risk of withdrawal symptoms.

  • Bridging therapy: Short-term use of a different class of medication (like corticosteroids, NSAIDs, or triptans) to manage withdrawal headaches.

  • Preventive treatment: Initiate a prophylactic medication like a tricyclic antidepressant, beta-blocker, antiepileptic, or CGRP inhibitor to reduce headache frequency and severity.

  • Acute treatment: Educate on the appropriate use of acute treatment options for breakthrough headaches.

• Other:

  • Physiotherapy: For associated neck pain or tension-type headaches.

  • Cognitive behavioral therapy: Useful to address potential contributing factors like stress, anxiety, or depression.

  • Follow-up: Regular outpatient follow-ups to monitor progress and adjust treatment plan.