A 41-year-old woman has had migraine attacks since adolescence. For two years she has had headache almost every day and takes two to four codeine-combination tablets daily. She says the drug no longer works and asks for something stronger.
The neurological examination is normal. She has used the drug on 26 days in the past month.
What does a stronger painkiller do?
This is chronic migraine plus medication-overuse headache. A codeine combination on 10 or more days a month meets that bar. A stronger tablet, usually a stronger opioid, tightens the cycle.
Treatment is to limit the acute drug and start migraine prevention, after saying that pain may be briefly worse for a week or two. That needs a plan. It is not an abrupt stop with no follow-up.
This is a teaching vignette and refers to no identifiable patient. These pages are written for health professionals. They do not replace a history, examination, or clinical judgment. Treatment is decided for each patient individually.