A 28-year-old man comes to the office for a health maintenance visit. He has no history of serious illness but reports periodic headaches over the last several years that often respond to acetaminophen. Occasionally the headaches are severe enough to necessitate taking a sick day from work. He cannot recall specific triggers but notes that the headaches are usually unilateral. The patient does not use tobacco or illicit drugs. He drinks alcohol socially and 2-3 cups of coffee daily. He is a software engineer and often works at a computer 10-12 hours a day. His sister has a history of migraines. Vital signs are within normal limits. Physical examination, including neurological examination, is normal. The patient states that the prior headaches were of similar nature and recurred several days in a row before remitting. Recently, the periods of active headaches have increased in duration with no remission. Which of the following is the best pharmacotherapy for headache prevention in this patient?

Question

A 28-year-old man comes to the office for a health maintenance visit.  He has no history of serious illness but reports periodic headaches over the last several years that often respond to acetaminophen.  Occasionally the headaches are severe enough to necessitate taking a sick day from work.  He cannot recall specific triggers but notes that the headaches are usually unilateral.  The patient does not use tobacco or illicit drugs.  He drinks alcohol socially and 2-3 cups of coffee daily.  He is a software engineer and often works at a computer 10-12 hours a day.  His sister has a history of migraines.  Vital signs are within normal limits.  Physical examination, including neurological examination, is normal. The patient states that the prior headaches were of similar nature and recurred several days in a row before remitting.  Recently, the periods of active headaches have increased in duration with no remission.  Which of the following is the best pharmacotherapy for headache prevention in this patient?

Quizplus · Accepted Answer

Explanation: Patients with cluster headache typically have 1-8 episodes a day over weeks or months. Although several medications are effective for acute treatment of cluster headaches, the repeated use of abortive medications can lead to rebound headaches and toxicity. As such, patients with cluster headache should receive preventive treatment at the onset of a cluster period to mitigate symptoms. The first-line therapy for cluster headaches that typically last >2 months is verapamil. This medication is usually initiated at 240 mg and titrated up as needed. (Choice A) Carbamazepine is an anticonvulsant that can be useful in patients with trigeminal neuralgia but is not typically used in cluster headaches. Topiramate, another anticonvulsant, is sometimes added to verapamil therapy in patients with cluster headaches. (Choice B) Indomethacin is a nonsteroidal anti-inflammatory drug that may be useful for acute treatment of tension-type or migraine headaches, but it is not an effective preventive therapy for cluster headaches. (Choice C) Propranolol can be used to prevent migraine headaches but is not an effective preventive therapy for cluster headaches. This patient with unilateral orbital headache associated with autonomic symptoms is more likely to have a cluster headache than migraine. (Choice D) Sumatriptan is useful for acute treatment of cluster headaches but is not used for chronic prevention. Educational objective: Patients with cluster headache should receive preventive treatment at the onset of a cluster period. Verapamil is considered the agent of choice for the prevention of episodic and chronic cluster headaches. References: Verapamil in the prophylaxis of episodic cluster headache: a double-blind study versus placebo. (http://www.ncbi.nlm.nih.gov/pubmed/10746617) Management of chronic cluster headache. (http://www.ncbi.nlm.nih.gov/pubmed/21107766)

A 28-Year-Old Man Comes to the Office for a Health