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Ask Dr. D. Love Your Own Question
Dr. D. Love
Dr. D. Love, Doctor
Category: Medical
Satisfied Customers: 19312
Experience:  Family Physician for 10 years; Hospital Medical Director for 10 years.
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My 24 year old son has had a constant severe headache 24/7

Customer Question

My 24 year old son has had a constant severe headache 24/7 without respite since October 2014, and is at his wits end. He does sleep 8 hours per night but not rest and is constantly tired and can not function or even focus until 3pm in the afternoon. He still works but his job performance is suffering greatly as he can not concentrate and is on autopilot as are all other aspects of his life. We suspect he is depressed and the GP has put him on Amitriptyline 8 weeks ago which does not seem to make any difference at all. He also suffers from loss of appetite, twitching, restless and tired legs. He has been tested for sleep apnea which he does not seem to have. Can you help or at least suggest some optionse specially as he is in Aberdeen and we are in London so the distance makes it hard for a mother to help.
Many thanks,
Rachelle Peterson
Submitted: 2 years ago.
Category: Medical
Expert:  Dr. D. Love replied 2 years ago.
Hello from JustAnswer.
I am sorry that your son is having so much difficulty.
It will help if you could provide some further information.
What dose of amitriptyline is he currently taking?
Has he had any imaging test of the head, such as a CT scan or MRI?
Customer: replied 2 years ago.
Not sure about the dosage and no he has not had an CT scan or MRI, on the Nhs it takes too long the GP mentioned he will be on a waiting list until 2016 but we are so desperate that wiling to go private if this helps.
Expert:  Dr. D. Love replied 2 years ago.
Thank you for the additional information.

There are several issues to consider in this situation.

There are several common causes of chronic daily headache.

The most common cause would be muscle contraction headaches, also called tension headaches. Some people can have complex headaches, with both muscle contraction and migraine components, but it is very unusual to have daily migraine headaches. It is also possible to have daily headaches from sinus inflammation or infection, although to be present for this length of time, it is more likely to be inflammatory. It is also rarely possible that daily headaches can be related to an anatomic abnormality, such as a growth in the brain. This is far less common than these other causes, but is more of a concern in someone with other neurologic symptoms or if the headache is more persistent or severe. There also are certain inflammatory conditions that can present with daily headache.

Depression can also contribute to a chronic headache syndrome, most often by exacerbation of muscle contraction headaches, although it can also affect many other headache causes.

One of the other issues to consider in someone with chronic daily headaches is whether there is any substance being ingested that can contribute to the headaches. The most common offending substance in this scenario is caffeine, but it also can occur with alcohol or certain recreational drugs. Caffeine is a frequent problem because caffeine can frequently help with headaches, which is why it is included in certain over the counter headache medicines. Caffeine is available in many sources, though, and any source of caffeine should be considered. If caffeine is used or ingested more frequently or in high doses, it can make the problem worse. The primary effect on worsening the headaches is while the levels are dropping in the body, so the headaches can get very severe when trying to stop the caffeine.

I ask about the dose of amitriptyline because the dose will vary according to why the drug is being used. Although the amitriptyline is always listed as an antidepressant, it usually requires relatively high doses when used for depression, usually in the range of 100 - 300 mg per day. However, amitriptyline can be used for many other conditions, including as a preventive medicine for muscle contraction and migraine headaches. When used for headaches, the dose is usually in lower doses, frequently 25 -50 mg per day, although sometimes it requires a higher dose.

From the perspective of the cause of the headache, an imaging test is commonly considered for persistent daily headache, although I understand the frustration in getting the test scheduled. There also are blood tests that can be done to screen for inflammation, such as a sed rate or C-reactive protein.

Although treatment is, of course, dependent upon the underlying cause of the headaches, the amitriptyline is a reasonable choice for the more common causes of headache. If he is on a low dose, then increasing the dose would be a reasonable consideration. It also would be appropriate to consider treatment for the depression, either with a higher dose of amitriptyline or with a newer medicine that has fewer side effects, such as the SSRIs, which are numerous medicines, including fluoxetine, sertraline, and citalopram. If he is ingesting a large amount of caffeine, then he should get off the caffeine.

If I can provide any further information, please let me know.