50-year-old female with history of high blood pressure and migraines
History of present illness: A 50-year old female patient presents for medication management of migraines, She was first diagnosed with migraines ten years ago, at which point she would experience them once every 3-4 months. She started menopause at 48 years of age, with hot flashes as her most persistent and noticeable symptom. She was taking Excedrin when migraine symptoms would start (rapidly worsening distinct headache combined with nausea), but then she started experiencing auras with every third migraine or so. She was given lasmitidan to take at migraine onset, particularly to help with her severe senstivity to light and sound. She reports the drowsiness she gets is "brutal," and makes daily functioning difficult. The patient's daughter is about to give birth to her grandson, and so she is particularly concerned that she will not be able to reliably take care of the newborn and help her daughter out.
Social history: Patient denies tobacco, alcohol and ilicit drug use. She lives with her husband. She is a product manager at a local SaaS company.
Medication: Lasmitidan as needed. Excedrine as needed. Allegra daily during spring/fall allergy seasons.
Past medical history: Menopause began in 2018. Personal history of high blood pressure. Father died of stroke. Mother had a heart attack and bypass surgery.
1. How would you alter the patient's medication regimen to address her concerns?
2. Given her fluctuating hormone levels and their potential effects, how often would you recommend this patient should follow up?