Case of the Month #7: Chronic fatigue, low mood and headache

Differential Diagnosis 

1. Migraine  

2. Chronic medication overuse headache 

3. Cervicogenic headache 

4. Headache of sinister origin 

5. Chronic Fatigue syndrome 

6. Anaemia leading to fatigue, poor sleep and headaches  

7. Hypothyroidism leading to fatigue, weight gain and headaches 

8. Depression, lack of motivation leading to fatigue, poor sleep and headaches 

Review 

Although several patients referred to the pain clinic come with a definitive diagnosis, it is not unusual to be faced with such patients, presenting with multiple symptoms which have not been fully investigated.  

It is useful to consider the classification of headaches (see reference 1 below) when considering the aetiology of headaches.  Several pain clinics across the country run joint headache clinics conjointly with a neurologist and this is extremely useful in particular when faced as in this case with an undiagnosed patient. There are several “Headache Pathways” and I have referenced the one used by the Walton Centre in Liverpool as an excellent example (see reference 2 below). 

This patient presented with several possible underlying issues - the history is suggestive of migraine with aura with a hormonal trigger in relation to her periods. The history of associated nasal congestion and facial flushing suggests that she is suffering from short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT).  There is also a component of medication overuse headache in association with her regular intake of analgesics.  Moreover, the history of depression, anxiety and chronic painful neck would suggest that there is a component of tension type and/or cervicogenic headache.  It is unlikely from the presenting history that there is a sinister or malignant cause for the headaches. 

Poor sleep can also be a trigger of headaches as can be chronic headaches associated with chronic fatigue syndrome.  A high body mass index can also lead to an element of obstructive sleep apnoea which can in turn lead to unrefreshed sleep, and further fatigue and headaches. Anaemia potentially due to her heavy periods could also be a component leading to chronic fatigue further compounding her symptoms. 

This patient clearly needs further evaluation and at the least some baseline investigations, looking at a full blood count, ESR, thyroid function test, serum Iron levels.  If the pain clinic does not have joint neurology clinics, this patient requires a referral to a neurologist for further evaluation. 

Management should include a holistic approach aimed at both the pharmacological prophylaxis and management of her pain, but also addressing her ongoing anxiety and depression with input from a clinical psychologist.  Seeing a specialist physiotherapist would also be helpful in terms of helping her improve neck pain, learning relaxation techniques and generally improving her level of function. 

Pharmacological management and prophylaxis will be guided by what is considered to be the prime underlying diagnosis.  It is likely that withdrawal of the regular analgesic medications that she was taking, in particular the regular codeine is likely to help (medication overuse headache). Use of preventatives such as Topiramate or Sodium Valproate would need to take into consideration the fact that she is young and may wish to have further children, both drugs being teratogenic.   I recommend reading the NICE guidelines CG150 - Headaches in over 12s: diagnosis and management first published in 2012 and recently updated in May 2021.  (Reference 3 below) 

Further reading on Migraine and Headaches is available in this month’s recommended reading and Journal Club, both of which have been dedicated to this topic.