A 31-year-old female presents to her GP with headaches. She describes these as "pounding" and located across her temple unilaterally, usually lasting for around 10 hours. These headaches are associated with significant nausea and are quite debilitating - when they occur, she has to take the day off work which is impacting her career progression. She has been taking regular paracetamol and ibuprofen during episodes with only moderate relief. She is having 1 episode per week at present.

What is the most likely diagnosis?

Options:
explanation: Over the counter analgesia, particularly paracetamol is the most common cause of analgesia overuse headache due to its use being relatively unrestricted. It is an important differential to consider in patients presenting with chronic/recurrent headaches. The criteria to consider this diagnosis is the use of the medication on 2-3 days per week and 10 or more days per month for at least 3 months - these episodes are only happening once per week and have the characteristic quality of a migraine
name: Analgesia overuse headache
label: e
answer: no
explanation: The headache experienced in a SAH is often described as a "thunderclap" headache, referring to the sudden onset and severe quality of the pain, which patients often describe as "the worst headache of my life"
name: Sub-arachnoid haemorrhage (SAH)
label: c
answer: no
explanation: Cluster headaches are a rare form of headache disorder compared with migraine and tension headaches. They are most common in younger male patients, and the pain is classically very extreme, acute in onset (comes on to maximal intensity within minutes) and is localised around one eye (which can become red). Episodes are short compared with migraines, with the pain lasting less than 3 hours (compared to migraines which last between 4-72 hours). The patient often experiences restlessness and agitation during episodes due to the intensity of the pain. They are called "cluster headaches" as they tend to occur in clusters, with periods of frequent attacks (can be several attacks per day) interspersed with periods of no headaches, which can even extend for years
name: Cluster headache
label: b
answer: no
explanation: Tension headaches tend to occur across the frontal/forehead region, typically bilaterally and do not have the characteristic throbbing/ pounding character of a migraine. They are also not strongly associated with nausea and are not as disabling, with patients usually able to continue with their work/ activity despite the pain
name: Tension headache
label: d
answer: no
explanation: The POUND criteria for migraine highlight the key symptoms of the condition, all of which are being experienced by this patient. The headache is **P**ulsatile in nature, and each episode lasts between 4-72 h**O**urs. The pain is **U**nilateral, associated with **N**ausea +/- vomiting and is significantly **D**isabling for the patient, preventing them from going about their usual daily activities. Patients may also experience a preceding aura, with either visual or sensory symptoms. Generally, migraines are not _fully_ responsive to simple analgesia such as paracetamol and ibuprofen - specific relief can be achieved with the use of an antiemetic and sumatriptan. In patients where migraines are occurring very frequently, prophylaxis can be considered with medications including propranolol or topiramate
name: Migraine
label: a
answer: yes

Correct answer: a