35 y/o woman presents with headaches that are unilateral (but can change sides), associated with light and noise sensitivity. The headaches are associated with nausea. When she has a headache, she has trouble functioning at work and home. Patient reports headache frequency to be approximately 9-10 per month. Her neurologic exam, imaging and funduscopic exam were normal. She is not overweight but sleeps poorly.
Patient was diagnosed with migraine and given education on sleep hygiene and migraine preventive treatment. She was started on amitriptyline. At her recheck appointment, patient reported that amitriptyline did help her sleep, but did not significantly improve her migraine headaches. Amitriptyline was stopped and replaced with topiramate. At her recheck appointment, it was determined that although her migraine is down to 5-6 episodes per month (this means more than 1 episode per week), she continues to have an impact on her daily activities.
What would you try next for migraine prevention? Propranolol, an anti-CGRP monoclonal antibody, or another preventative? Why?
1. American Headache Society. The American Headache Society Position Statement on integrating new migraine treatments into clinical practice. Headache. 2019;59(1)1-18.
CGRP = calcitonin gene-related peptide