A 27-year-old woman presents to her primary care clinic for evaluation of recurrent headache over the past several months. She describes a unilateral, throbbing headache that is partially relieved by resting in a quiet dark space. She has been taking over-the-counter acetaminophen without relief of symptoms. She is a first year medical student and has not been sleeping well due to stress of upcoming exams. The patient has a history of major depression and is currently taking sertraline daily. Vital signs are within normal limits, and the physical examination is otherwise unremarkable. Which of the following is the best treatment for the prevention of this patient’s headache?
A. Topiramate
Correct: See main explanation
B. Amitriptyline
Incorrect: Amitriptyline is a tricyclic antidepressant often used as a prophylactic medication for patients with recurrent migraine headaches. Given this patient’s concurrent use of sertraline, the addition of amitriptyline increases this patient’s risk of serotonin syndrome and should be avoided.
C. Metoclopramide
Incorrect: Metoclopramide is often used in the treatment of acute migraine attacks, especially with associated nausea and vomiting. It is not a useful medication in prophylactic treatment of migraine.
D. Ibuprofen
Incorrect: Ibuprofen and other NSAIDs are treatments often used for acute migraine symptoms or tension headaches. NSAIDs have little role in the prophylactic treatment of migraines.
E. Sumatriptan
Incorrect: Like ibuprofen and other NSAIDs, triptan medications are often used for the acute abortive treatment of migraine symptoms, but they are not used in the prophylactic treatment of migraines.
Main Explanation
This patient with recurrent, unilateral, throbbing headaches with associated photophobia is most likely suffering from acute migraine headache. Of the medications listed above, the most appropriate prophylactic treatment for this patient is topiramate.
Migraine is a type of primary headache, thought to be due to activation of the trigeminovascular system causing neurogenic inflammation and over-sensitization of neurons. Typical features include recurrent unilateral throbbing headaches with associated nausea, vomiting, photophobia and/or phonophobia. Additionally, an aura may precede the headache, which is usually a neurologic symptom such as altered taste/smell, vision changes, or alterations in hearing. The symptoms of migraine headaches generally last 4-72 hours.
Common triggers of migraine include stress, fasting, certain foods like red wine and chocolate, sleep disturbances, weather changes, and menstruation. Treatment of migraines is divided into acute or abortive treatment and prophylactic treatment. Acute treatment includes first-line NSAIDs, like naproxen. Second-line agents include sumatriptan and ergotamines, like dihydroergotamine, and antiemetics, like metoclopramide. For frequent migraine headaches that are severe, long-lasting or disabling, prophylactic agents like topiramate, divalproex sodium, tricyclic antidepressants (amitriptyline, venlafaxine) or beta blockers (metoprolol, propranolol) can be used. Calcitonin gene-related peptide (CGRP) antagonists (e.g., galcanezumab, rimegepant) have also recently been approved by the FDA for the prevention of migraine headache.
Major Takeaway
Migraine is a type of primary headache that is characterized by recurrent unilateral throbbing headaches with associated nausea, vomiting, photophobia and/or phonophobia. Treatment involves both abortive (e.g., naproxen, sumatriptan, metoclopramide) and prophylactic (e.g., topiramate, amitriptyline, propranolol).
References
Silberstein SD. Migraine. Lancet. 2004 Jan 31;363(9406):381-91. doi: 10.1016/S0140-6736(04)15440-8. PMID: 15070571.
Dodick DW. Migraine. Lancet. 2018 Mar 31;391(10127):1315-1330. doi: 10.1016/S0140-6736(18)30478-1. Epub 2018 Mar 6. PMID: 29523342.
Curry, M. (2017, May 18). Rosen's Emergency Medicine: Concepts and Clinical Practice. Retrieved from https://www.us.elsevierhealth.com/rosens-emergency-medicine-concepts-and-clinical-practice-9780323354790.html. ISBN: 0323354793
