Question of the Month – September 2019 Written by:Genevieve D’Souza, MDStanford University A 16 year old boy presents to the pediatric chronic pain clinic with 5 month history of daily headaches. Onset of headaches correlated with the start of 9th grade in a new high school. His headache is in the occipital area radiating to the top of his head bilaterally. His grades have dropped significantly as he is absent 2-3 days/week and comes home early from school the other days. He reports being stressed from missing all the school work and now having to make up all the work. He reports difficulties in falling asleep and is playing videogames for 2-4 hrs at night as he can’t fall asleep. He was trialed on triptans and gabapentin but had to discontinue them due to side effects. Review of the chart reveals a normal MRI of the head. On examination, he has a normal neurological exam with positive bilateral occipital neuralgia. He has been taking acetaminophen every 4 hours and ibuprofen every 6 hours, in scheduled fashion. Which option would not be the recommended next step in management? A. Recommend discontinuation of daily acetaminophen/NSAIDS to prevent medication overuse headache. B. Consider administration of bilateral occipital nerve blocks for occipital neuralgia. C. Formal referral to rest of the multidisciplinary chronic pain team in order to incorporate lifestyle modification, sleep hygiene skills, acupuncture, and referral to a psychologist. D. Continue daily acetaminophen and ibuprofen, and also add triptans.