The Bustelo Bolus: Caffeine Withdrawal Mimicking Status Migrainosus in a Patient With Systemic Lupus Erythematosus and Systemic Sclerosis Overlap

Caffeine is the most widely consumed psychoactive substance in the world, and abrupt cessation in habitual users produces a stereotyped withdrawal syndrome whose dominant feature is headache. Although caffeine withdrawal is a familiar diagnosis in ambulatory and perioperative practice, it is easily overlooked in hospitalized patients on a complex medical service, where the differential for new headache is dominated by autoimmune, infectious, and vascular etiologies. We report a 33-year-old woman with overlap connective tissue disease (systemic lupus erythematosus, mixed connective tissue disease, and systemic sclerosis) admitted for doxycycline-associated Stevens-Johnson syndrome and oral mucositis. On hospital day 3, she developed an excruciating bilateral throbbing headache with photophobia, phonophobia, and nausea. Magnetic resonance imaging of the brain and magnetic resonance angiography of the head were unremarkable apart from non-specific subcortical white matter foci. The headache was refractory to six acute migraine therapies and to a status migrainosus protocol, and a lumbar puncture was being prepared. After ingestion of approximately 8 oz of brewed black coffee from the nursing station, the headache resolved within 30 minutes and did not recur, and the planned lumbar puncture was deferred. The patient was discharged the same day. The presentation met the International Classification of Headache Disorders, 3rd edition, criteria for caffeine withdrawal headache. The case illustrates how an inexpensive caffeine challenge can serve as both a diagnostic and a therapeutic step before invasive workup in a hospitalized patient whose habitual oral caffeine intake has stopped abruptly. Routine intake history, including caffeine, should be elicited at admission for any patient anticipated to be nil per os or to have impaired oral intake.