A 26-year-old man comes to the office due to severe headaches that are increasing in frequency. The patient describes episodic, right-sided hemicranial throbbing or pulsating headaches accompanied by nausea and photophobia. The headaches began when he was in high school, but lately they have become more frequent and are affecting his work. The patient takes nonsteroidal analgesics and sumatriptan for the pain and metoclopramide for nausea. He has no other medical conditions and no drug allergies. Vital signs are within normal limits, and physical examination shows no abnormalities. A recent brain imaging study was normal. Which of the following pharmacotherapies would be most helpful to prevent recurrences of this patient's headache?

Question

A 26-year-old man comes to the office due to severe headaches that are increasing in frequency.  The patient describes episodic, right-sided hemicranial throbbing or pulsating headaches accompanied by nausea and photophobia.  The headaches began when he was in high school, but lately they have become more frequent and are affecting his work.  The patient takes nonsteroidal analgesics and sumatriptan for the pain and metoclopramide for nausea.  He has no other medical conditions and no drug allergies.  Vital signs are within normal limits, and physical examination shows no abnormalities.  A recent brain imaging study was normal.  Which of the following pharmacotherapies would be most helpful to prevent recurrences of this patient's headache?

Quizplus · Accepted Answer

11ec160b_3c11_2300_9249_9f0d38fd2086_MD0001_00 This patient has recurrent migraine, a disorder characterized by severe, unilateral headaches, frequently associated with nausea and sensitivity to light and sound. Migraine therapy is divided into abortive therapy for acute pain control and preventive therapy to reduce the frequency and severity of the headaches. Commonly used abortive medications include mild analgesics (eg, nonsteroidal anti-inflammatory drugs, acetaminophen), triptans (eg, sumatriptan), antiemetics (eg, metoclopramide, prochlorperazine), and ergotamines. These medications reduce symptoms at headache onset but do not prevent further headaches. Patients with frequent migraines or significant impairment due to the symptoms warrant preventive therapy. Topiramate is an anticonvulsant that reduces the frequency of migraines. Other preventive medications include beta blockers (eg, metoprolol, propranolol), tricyclic antidepressants (eg, amitriptyline), and other anticonvulsants (eg, valproate). (Choice A) Capsaicin is derived from chili peppers and is useful as a topical therapy for neuropathic or musculoskeletal pain; it is not useful for treatment of migraine. (Choice B) Ergotamine has both agonist and antagonist activities on multiple neurotransmitters (eg, dopamine, serotonin, epinephrine) and acts as a vasoconstrictor. It is used for migraine abortion, not prevention. (Choice C) Hydrochlorothiazide is an antihypertensive that reduces sodium reabsorption in the distal convoluted tubule. Although beta blockers (another type of antihypertensive) are useful for migraine prevention, hydrochlorothiazide is not indicated for treatment of migraines. (Choice D) Sertraline is a selective serotonin reuptake inhibitor (SSRI) used for depression and anxiety. Although tricyclic antidepressants are used for migraine prevention, SSRIs have not been shown to prevent migraines. Educational objective: Migraine is an episodic disorder characterized by severe, often unilateral headache, commonly associated with nausea and sensitivity to light and sound. Treatment is divided into abortive therapy (eg, mild analgesics, triptans, antiemetics, ergotamines) for acute symptoms and preventive therapy (eg, beta blockers, tricyclic antidepressants, anticonvulsants [topiramate, valproate]) to reduce the frequency of headaches.

A 26-Year-Old Man Comes to the Office Due to Severe