Headache OSCE - Medication Overuse Headache

Case Overview

• Age/Sex: 51-year-old female
• Occupation: Office worker (administrative assistant)
• Setting: Primary care clinic, worried about a persistent headache
• Chief complaint: "I've had a headache for months and it's getting worse; I take painkillers a lot."

Patient Script

Who I Am

I'm 51, I work full-time at a desk job, and I look after my home and two teenagers.

What Brings Me In

I've had a headache nearly every day for months, and I'm worried it might be something serious — or that I'm making it worse by taking so many painkillers.

My Story

For most of my adult life I've had occasional headaches with stressful weeks, but for the last about 4 months I've had a headache on most days, usually a dull, pressing ache across my forehead and temples that I wake up with. The pain is constant but fluctuates, sometimes worse in the morning and sometimes after a long day at the computer. Over the last 6 months I've been taking over-the-counter painkillers (paracetamol and ibuprofen) almost every day — probably 20–25 days a month — because they help a bit. I also started taking a stronger combination tablet from the pharmacy a few times a week in the past few months when the pain was bad.

A few points you might find relevant: I had a sinus infection two winters ago and had antibiotics — the doctor said the scan looked fine then. About 3 weeks ago my GP changed my blood pressure pill because my BP was a bit high; that started around the time the headaches felt a bit worse for a few days but then settled. I also drink more coffee when I'm stressed at work. The headaches sometimes make me feel a bit nauseous but I don't get an aura or vision loss. I have trouble concentrating at work and I'm worried it could be a brain tumour or a stroke.

My Medical Background

• Past medical history: lifelong intermittent headaches (worse with stress), treated sinus infection 2 years ago
• Medications: paracetamol + ibuprofen most days (20–25 days/month), occasional stronger combination pain tablets a few times/week bought at the pharmacy; recently started an antihypertensive 3 weeks ago
• Allergies: none known
• Social: drinks 1–2 glasses of wine socially per week, drinks 2–3 coffees/day, non-smoker
• Family history: mother had migraines; father has high blood pressure

What I Think & Worry About

• I think it's either something serious in my head like a tumour or stroke, or it might just be stress from work.
• I'm worried I'm doing harm by taking painkillers so often, but I can't get through the day without them.
• I want to know if stopping the tablets will help and whether I need any scans.

If You Ask Me About Other Symptoms...

• Vision: sometimes blurred if I'm tired, but no double vision or sudden loss of sight
• Jaw/temples: no jaw pain when chewing, and I don’t have any scalp tenderness
• Fever/weight loss: none
• Neck stiffness: I feel stiff from sitting at a desk, but no severe neck stiffness or meningism
• Neurology: no weakness, numbness, slurred speech, or seizures
• Sleep: I wake a few times at night and often wake with the headache
• Mood: I'm a bit more irritable and anxious about the headaches, sleep is worse than usual

---

Clinical Summary

Examination

• General: alert, well-looking middle-aged woman, mildly anxious
• Vitals: BP 138/86 mmHg, HR 78 bpm, RR 16/min, Temperature 36.8°C, BMI 27 kg/m2
• Head and neck: no scalp tenderness, no temporal artery prominence or tenderness
• Eyes: visual acuity normal for correction, fundoscopy no papilloedema
• Cranial nerves: II–XII intact
• Motor/sensory: normal power, tone and sensation in all limbs
• Cerebellar: normal finger-nose and gait
• Neck: supple, mild pericranial muscle tenderness on palpation

Investigations

• Full blood count: WBC 6.5 x10^9/L, Hb 13.2 g/dL, platelets 250 x10^9/L (normal)
• ESR: 8 mm/hr (normal)
• CRP: <5 mg/L (normal)
• Basic metabolic panel: electrolytes within reference range
• Optional imaging: Non-contrast CT head: no acute intracranial abnormality (performed earlier in previous year for separate issue); MRI brain not immediately indicated given normal neuro exam and lack of red flags

Diagnosis

• Primary diagnosis: Medication Overuse Headache (probable) — supported by daily/near-daily headache for ~4 months and regular use of simple analgesics (paracetamol/ibuprofen) 20–25 days per month for ≥6 months, with pericranial tenderness and no focal neurological signs or inflammatory markers to suggest alternative serious pathology.

• Differential diagnoses and reasoning:

  • Chronic migraine or chronic tension-type headache: likely underlying primary disorder given long history of intermittent headaches; MOH is superimposed due to frequent analgesic use
  • New daily persistent headache (NDPH): less likely due to gradual escalation over months rather than a sudden onset
  • Sinus headache/chronic rhinosinusitis: less likely — no persistent nasal symptoms, prior sinus infection was historical and not temporally related
  • Medication side effect from recent antihypertensive: temporal relationship poor (BP pill started 3 weeks ago) and headache preceded it
  • Temporal arteritis: unlikely given age borderline but normal ESR/CRP and absence of jaw claudication or scalp tenderness
  • Intracranial mass: unlikely given normal neuro exam and no progressive focal signs; consider imaging if red flags or progressive symptoms

Management

• Explain diagnosis empathetically: advise that frequent use of analgesics can paradoxically perpetuate headaches (Medication Overuse Headache) and that stopping the overused medications is the key first step.
• Stop offending analgesics: advise immediate withdrawal of regular paracetamol/ibuprofen/combination tablets; discuss that abrupt cessation is commonly recommended for simple analgesics, with warning of possible transient worsening over 1–2 weeks.
• Provide symptomatic/bridging options: consider short course of naproxen or a limited prescription for a stronger analgesic for a few days under supervision if needed; consider antiemetic for nausea if severe during withdrawal.
• Start preventive therapy: consider starting low-dose amitriptyline 10–25 mg nightly (particularly helpful for tension-type features and sleep) or refer for consideration of other preventives if features of chronic migraine (e.g., topiramate, beta-blockers or specialist options).
• Non-pharmacological measures: advice on sleep hygiene, caffeine reduction, regular exercise, stress management, ergonomic review at work, consider physiotherapy for pericranial tenderness, and CBT or relaxation therapy if required.
• Safety netting and follow-up: arrange follow-up in 4 weeks to review withdrawal progress, headache frequency, and consider neurology/headache clinic referral if no improvement or if neurological red flags develop.
• Address comorbidities: review blood pressure management and ensure antihypertensive is tolerated but not blamed for the chronic pattern unless clear causality emerges.

Key Learning Points

• Medication overuse headache should be suspected in patients with daily or near-daily headaches and regular use of acute analgesics (simple analgesics >15 days/month or combination/triptans/opioids >10 days/month) over >3 months.
• Management centers on stopping the overused medications, providing symptomatic support during withdrawal, initiating appropriate preventive therapy for the underlying primary headache, and addressing lifestyle factors.
• Always assess for red flags (fever, focal neurological signs, papilloedema, systemic symptoms) and investigate as necessary, but normal neurological exam and inflammatory markers make sinister causes less likely in this scenario.