A 30-year-old man comes to the office for worsening headaches. He has had episodic, unilateral, throbbing headaches associated with nausea and occasional vomiting for the past several years. Over the last 6 months, the headaches have become progressively worse and now occur twice a week. The patient usually takes abortive therapy at the onset of a headache, but recently he went to the emergency department 3 times due to uncontrolled pain. Other medical conditions include asthma and gastroesophageal reflux. He was hospitalized twice over the last year for asthma exacerbations but has never required endotracheal intubation. He does not use tobacco, alcohol, or illicit drugs.
Vital signs are within normal limits. BMI is 32 kg/m². Examination shows no abnormalities. Recent brain MRI was normal.
Which of the following is the best approach for long-term management of this patient's headaches?

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Quizplus · Accepted Answer

11ec193a_9881_7021_853d_6951d8fb69a3_MD0002_00 This patient's presentation suggests migraine headache, a global neurologic disorder likely due to cortical spreading depression. Migraine therapy is divided into abortive treatments for acute pain control and preventive treatments 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 dihydroergotamine. These medications reduce symptoms at headache onset but do not prevent further headaches (Choice B). Patients with recurrent migraines (>4 times a month, lasting >12 hours) or significant impairment due to migraines require preventive therapy. A number of agents should be considered, including beta blockers (eg, metoprolol, propanolol), antidepressants (eg, amitriptyline), and anticonvulsants (eg, topiramate), with the choice dependent on side effect profile and patient characteristics. Of these, topiramate is the best choice for this young patient with obesity due to its relatively mild side effect profile, including paresthesia, fatigue, and weight loss (a unique side effect seen in up to ~15% of patients). It is also an excellent choice in patients with concurrent epilepsy, but it should be used with caution in those with a history of kidney stones (increased risk) and women of childbearing age (pregnancy category D). (Choice A) Opioid pain medications are not recommended in the treatment of migraine headaches as they are less effective than other abortive therapies, can lead to medication overuse headaches, and carry the potential for dependence/addiction. (Choice C) Propranolol is an effective migraine preventive agent but is not recommended in patients age >60, smokers, or those with existing lung disease (eg, asthma). This patient has required recent hospitalization due to asthma and could develop worsening bronchospasm with propranolol. (Choice E) Verapamil is useful for prophylaxis of cluster headaches, but data on benefit in migraine prevention are limited. Despite this, it is often prescribed for women of childbearing age due to its favorable side effect profile and relative safety during pregnancy. It would not be first-line therapy for this patient. Educational objective: Preventive therapies should be used for patients with migraines >4 times a month, lasting >12 hours, or causing significant impairment. Common options include beta blockers, antidepressants, and anticonvulsants. Beta blockers should be avoided in asthmatic patients due to the risk of bronchospasm. __________ References: Current practice and future directions in the prevention and acute management of migraine. (http://www.ncbi.nlm.nih.gov/pubmed/20170842) Preventive migraine treatment. (http://www.ncbi.nlm.nih.gov/pubmed/19289224)

A 30-Year-Old Man Comes to the Office for Worsening Headaches