When treatment becomes the cause of the disease

Abstract

Introduction: Headache is a common complaint and self-medication is not uncommon. This article reports the approach to medication overuse headache (MOH) in a patient who self-medicated with analgesics, whose intervention was hampered by poor adherence to medical follow-up.

Case Description: 41-year-old woman, cleaning employee. History of migraine since adolescence, which worsened after her second delivery, presenting with weekly episodes without relief after several treatments were prescribed. In 2015, after referral to a Neurology consultation, she started prophylaxis with amitriptyline, which she suspended, missing the follow-up appointment. In the three years that followed, she only attended primary care consultations motivated by acute illness, without regular appointments. On Jan/2018, she went to the emergency department due to persistent migraine, and again she was referred to a Neurology consultation, where it was detected that she self-medicated with over twenty suppositories of paracetamol + codeine in each episode of migraine. Topiramate was prescribed and a new consultation was scheduled. She suspended topiramate due to weight loss and missed the follow-up appointment. On Jan/2020, she consulted her family doctor reporting sadness, insomnia, constipation, and weight loss. She maintained the migraine and the use of suppositories. After screening for organic causes, she was diagnosed with depressive disorder and MOH. It was explained that drug abuse could cause headaches and treatment would involve the cessation of that medication. She was medicated with antidepressants, and, in the next consultations, weight recovery, improved mood, less frequent headache, and reduced suppository use until withdrawal were documented.

Comment: MOH develops due to the excessive use of headache relievers, and the suspension of medication is the only effective treatment. This patient maintained a situation of medication overuse for eight months, resulting in MOH and risk of liver toxicity. The family doctor is crucial to early detecting and addressing drug abuse.