Quiz: What Is the Etiology of This Patient's Headaches?

Author:
Joseph A. Diamond, MD
Mount Sinai West/St. Luke's

A 63-year-old woman presents to your office with persistent headaches for the past 6 months. She has a medical history of hypertension, for which she is taking metoprolol; migraine headaches, for which she is receiving onabotulinumtoxinA injections every 3 months; type 2 diabetes mellitus, for which she is taking metformin; depression, for which she is taking bupropion; and gastroesophageal reflux disease (GERD), for which she is taking omeprazole. She says these headaches are quite different from her normal migraines, which are right-sided, can happen at any time of day, are associated with photophobia and nausea, and have significantly improved since starting onabotulinumtoxinA injections.

These new headaches predominantly occur upon awakening from sleep, are holocephalic, are described as “pressure” without nausea or photophobia, and generally disperse about 2 hours after awakening, regardless of whether she takes medication. She denies any snoring or witnessed apneas but does report rarely awakening with a gasping sensation and often having dry mouth, which she attributes to the air conditioner next to her bed. She also remarks that she has been having occasional problems falling asleep, “pacing” at night, and feeling an “itchiness” in her legs that is relieved with movement.

Joseph A. Diamond, MD, DABPN, DABSM, is an assistant professor of neurology at the Icahn School of Medicine at Mount Sinai; Neurology Clerkship Site Director at Mount Sinai West/St. Luke's; and Neurohospitalist at Mount Sinai West/St. Luke's in New York, New York.

Which of her medications is contributing to her problems falling asleep?

Joseph A. Diamond, MD, DABPN, DABSM, is an assistant professor of neurology at the Icahn School of Medicine at Mount Sinai; Neurology Clerkship Site Director at Mount Sinai West/St. Luke's; and Neurohospitalist at Mount Sinai West/St. Luke's in New York, New York.