A 24-year-old woman has a 5-year history of headaches characterized by pounding, throbbing pain. The headaches usually start at the back of the head, principally on the left side, and then encompass the entire head. She reports having headaches at least 3 to 4 days a week during which time she also experiences light and noise sensitivity. Naproxen and rizatriptan provide relief, but she has been taking the rizatriptan more often in the past 6 months due to an increase in frequency and severity of the headaches and is running out of her prescription before it is due for a refill. The patient has a history of anxiety, asthma, and reflux, and she underwent lithotripsy for a kidney stone. Current medications include albuterol, Montelukast sodium, sertraline 200 mg/day, and omeprazole 40 mg. Vital signs are as follows: BP 139/85 mm Hg, HR 89 beats/min. Her BMI is 34 kg/m2. Which of the following medications is the best option for preventive therapy?
A. Topiramate **
B. Divalproex sodium
** = Your answer
The patient’s headaches meet the criteria for migraine and their frequency warrants preventive therapy. Medication choice is based on a patient’s general condition, medical history, and current medication regimen.
All the medications listed generally are appropriate for preventive therapy; however, topiramate is not a good choice for this patient due to her history of kidney stones and propranolol is not appropriate due to her asthma.
Divalproex sodium is not recommended for women of childbearing age due to the potential for birth defects. Other potential side effects include severe weight gain and hair loss, which also precludes its use in patients with a high BMI.
Amitriptyline is not appropriate for patients on a relatively high dose of sertraline due to the potential for adverse drug interactions, including serotonin toxicity. Its side effects include weight gain; thus, it is not appropriate for this patient.
Candesartan has been widely used by headache specialists as a preventive treatment with good success.
* Silberstein SD. Preventive migraine treatment. Continuum Lifelong Learning Neurol. 2015;21(4):973-989.