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Man With Incapacitating Daily Headaches

Man With Incapacitating Daily Headaches

A 39-year-old man complains of severe daily headaches that he describes as throbbing and "burning," with a sensation
of pressure. He rates the severity of his pain as 8 to 10 on a 10-point visual analog scale (VAS) in which 10 is
the most severe. The mean duration of the headaches is 12 hours, and the mean frequency is 5 days per week. Between
the episodes of severe headache, he has constant "minor" headaches that are not as severe (mean severity, 3 to 5 on a
10-point VAS). Within the past 5 months, he has never been totally free of headache.
The patient's headaches started during his 20s. At that time, they were very severe but not as frequent. The frequency
of the headaches slowly increased over 2 to 3 years until they occurred on more than 15 days each month. For the past
7 years, he has had daily headaches, which have worsened and become disabling in the past 4 months.
His treatment history is extensive; he has tried a variety of appropriate medications, but none have enabled him to
control his headaches and to function normally. Preventative medications he has tried include verapamil, fluoxetine,
paroxetine, amitriptyline, divalproex, topiramate, and celecoxib. The abortive medications include several potent antimigraine
agents (sumatriptan, almotriptan, and zolmitriptan). In addition, for pain relief, he has tried over-the-counter
analgesics, oxycodone, and propoxyphene. For the past 7 months, he has used butalbital-containing medications every day.
A recent MRI scan and MR angiogram and results of a neurologic examination are all normal.

  • Which clues in the history and clinical picture point to the diagnosis?
  • How would you intervene to alleviate this patient's disabling headaches?
  • How would you institute effective preventative therapy?

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