1.3 Chronic migraine

Identification: Female patient, 42 years old, teacher, married, mother of two children.

History of Present Illness: The patient has been experiencing headaches for 15 years, initially episodic, with attacks occurring 1 to 2 times per month, characterized by pulsatile, unilateral pain of moderate to severe intensity, associated with photophobia, phonophobia, and nausea. Over the past 3 years, the attacks have become more frequent, currently occurring on average 20 days per month, with similar characteristics but greater intensity and duration. She reports that the attacks are triggered by stress, sleep deprivation, and hormonal changes. She has used various prophylactic treatments (propranolol, amitriptyline, topiramate) and abortive treatments (sumatriptan, naproxen) with unsatisfactory response. She reports a significant impact on quality of life, with impairments in daily and work activities.

Past Medical History: Major depression under treatment with sertraline 50 mg/day for 5 years. Grade I obesity (BMI 31 kg/m²). Denies other comorbidities.

Physical Examination: General: conscious, oriented, hydrated. Neurological: no motor, sensory, or cognitive deficits. Normal reflexes, intact cranial nerves. Other systems: no relevant alterations.

Complementary Exams: Cranial MRI: normal. Laboratory analyses (complete blood count, liver and renal function, TSH): within normal limits.