Migraine

Impression: Chronic migraine with medication overuse headache. Past Medical History: 1. Hypertension 2. Hyperlipidemia Current Medications: 1. Amlodipine 5mg daily 2. Atorvastatin 20mg daily 3. Sumatriptan 50mg as needed Management Plan: 1. Patient to be weaned off of sumatriptan and other acute medications. 2. Initiate topiramate 25mg daily, titrating up to 100mg daily as tolerated. 3. Schedule follow-up appointment in 3 months. Migraine advice to the patient and the GP: 1. Self-education: www.migrainetrust.org, website (triggers and coping with migraine subsections) 2. Relaxation/Mindfulness: a. Self-referral to psychology via IAPT NHS website b. Headspace app c. Online CBT 3. Acute therapies: a. Ibuprofen 800 mg or 900 mg of aspirin plus domperidone 20 mg or metoclopramide 10 mg – only considered a failure if unsuccessful on less than 1/3 occasions. b. To then switch to triptan taken together with an anti-emetic, [domperidone or metoclopramide], trying each triptan in turn in the following order: i. sumatriptan 50 mg o.d. or 20 mg nasal spray, ii. almotriptan 12.5 mg o.d., iii. rizatriptan 10 mg tablets or as wafers o.d., iv. zolmitriptan 2.5 mg increasing to 5 mg for subsequent attacks in patients not receiving satisfactory relief on 2.5 mg, v. eletriptan 40 mg o.d. c. If ineffective, use naproxen 500 mg plus most effective triptan plus anti-emetic. Principle: Any single drug should be tried at least three times to establish whether it is beneficial and only be considered a failure if unsuccessful on ≥2 out of 3 occasions. 4. Migraine prophylaxis: To improve the frequency and the impact of migraine, GP could consider starting one of the prophylactic medications, the following are the options: · Amitriptyline, starting at 10 mg nocte, increasing weekly towards 50 mg nocte, maximum 75 mg nocte · Propranolol, 10 mg bd, increasing weekly towards 40 mg bd, maximum 320 mg/day (remove if the patient has asthma) · Candesartan 4 mg daily increasing towards 8 mg bd For any prophylaxis, it needs to be continued for 6 weeks at the maximum dose (or maximum tolerated dose) before reviewing the headache diary and assessing efficacy. Thank you for referring this 35-year-old right-handed female who attended the neurology clinic. She is a teacher who has had a history of migraine headaches for 15 years. She describes her typical headache attack as starting with a visual aura lasting 20 minutes, followed by a throbbing headache on the left side of her head. The headache is associated with sensitivity to light and noise, nausea, and vomiting. The headache lasts for 12-24 hours. Triggers include stress and certain foods. The headaches significantly impact her ability to work and participate in social activities. She has previously tried sumatriptan, which provided some relief but is now being used more frequently than recommended. She has also tried propranolol, which was discontinued due to side effects. Her mother also suffers from migraine headaches. She lives with her partner and does not use alcohol, tobacco, or illicit drugs. She is fit to drive. Previous investigations include a normal MRI of the brain. The neurological examination: Cranial nerves II-XII intact. Normal motor strength and sensation. Reflexes 2+ and symmetrical. Gait and coordination are normal. Summary and recommendation: Based on the history, examination, and investigations, the patient's diagnosis is chronic migraine with medication overuse headache. I recommend weaning off of acute medications and starting topiramate for migraine prophylaxis. I will see her again in 3 months.