PUID: 42 || PLAB 2 Mock 4:: CounselingMedication17: Medication Overuse Headache

Practice a case with the AI patient 🤖

Summary:

This case involves a patient experiencing frequent headaches likely due to medication overuse, particularly of analgesics like paracetamol, ibuprofen, and sumatriptan. The scenario focuses on clinical recognition, appropriate management, and effective communication strategies to handle this condition in a time-constrained PLAB 2 station.

Key Points:

Headache Assessment

• Initial Approach:

  • Begin with an open-ended question: “Can you tell me more about these headaches?”

  • Use the SOCRATES method after initial open dialogue.

• History Clues:

  • Use of multiple analgesics frequently (paracetamol, ibuprofen, sumatriptan).

  • Headaches worsening in frequency and severity.

Diagnostic Red Flags

• Rule out serious causes: subarachnoid hemorrhage, meningitis, raised ICP.

  • Ask about:

    • Worst headache ever (scale 1-10).

    • Neck stiffness.

    • Visual disturbances.

    • Neurological signs.

Diagnosis

• Medication Overuse Headache (MOH):

  • Defined as headache occurring on ≥15 days/month in a patient with pre-existing headache disorder, worsened by frequent use of acute headache medications.

Important Considerations:

• Avoid over-investigation once diagnosis is apparent.

• Move to management early if diagnosis is clear and red flags are ruled out.

• Manage time to allow structured discussion of management steps.

Diagnostic Approach:

1. Open Question to explore the nature of headaches.

2. Use SOCRATES to structure symptom inquiry.

3. Ask about frequency, type, and names of medications used.

4. Assess for red flag symptoms.

5. Confirm diagnosis by linking clinical findings to medication pattern.

Management:

Explanation and Education

• Explain MOH in simple terms: overuse of pain medications can cause more headaches.

• Clarify neurochemical changes due to frequent analgesic use.

Pharmacological Management

• Gradual withdrawal of overused medications.

• Naproxen 500 mg BD short-term to manage withdrawal headaches.

• Consider prophylactics:

  • Amitriptyline (TCA).

  • Topiramate (antiepileptic).

Non-Pharmacological Measures

• Headache diary to track frequency and triggers.

• Lifestyle advice:

  • Adequate hydration.

  • Regular sleep and exercise.

  • Avoid caffeine and triggers.

  • Relaxation techniques.

Support and Resources

• Provide leaflets/pamphlets for home reading.

• Recommend support groups if psychological impact is present.

Safety Netting

• Return if:

  • Symptoms persist >2 weeks post-withdrawal.

  • New neurological symptoms appear (e.g., vision loss, confusion).

  • Unable to cope with withdrawal symptoms.

Follow-up

• Schedule follow-up appointment to reassess progress and adjust management.

Communication Skills:

• Always start with an open-ended question.

• Use patient-friendly language.

• Avoid over-rehearsed or lengthy phrasing—be concise and clear.

• Use empathic expressions appropriately without sounding artificial.

• Summarize diagnosis and management before time runs out and offer choices:

  • “Would you like to talk about lifestyle changes, medications, or follow-up first?”

Ethical Considerations:

• Informed consent: Clearly explain the rationale for medication changes.

• Non-maleficence: Avoid continued harm from analgesic overuse.

• Patient autonomy: Offer treatment options and allow shared decision-making.

Additional Resources:

• NICE guidelines on headaches.

• GMC’s Good Medical Practice – patient communication and ethical care.

• GMC feedback interpretation: Time management, structured consultations.

• Examiner top tips: Logical structure, empathy, and avoiding stock phrases.