Cough and Strain Headaches with Nausea

A 50-year-old man was referred by his GP for severe occipital headaches and neck pain that had been ongoing for over 5 years. He complained of intermittent neck pain and his headaches were becoming more severe. These headaches usually awakened him from sleep and were exceptionally severe in the morning. They were present most days but occasionally flared up to become even more severe. Nausea was also associated with the headaches, and he had described retching in the mornings. An optician had performed a fundoscopy which was reported as normal. Chronic migraine was suspected and patient had been prescribed antimigraine treatment and antiemetics, but they were not effective. Full blood count, ESR, U&Es, LFTs, bone profile, AST had been performed, and all were normal.