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June 23, 2021

Patient with Migraine with Aura Experiences Increasing Symptoms and Risks

History and Present Illness
Patient is a 46-year-old female that was diagnosed with migraine with aura approximately five years ago. The patient recently presented at the ED with signs of a first CVD, verified upon admission. She now presents at her PCP for follow-up and medication management. Her chief complaint today is continued instances of visual and sensory disturbances, along with mild nausea and intense headache.

Patient is compliant with her Type II diabetes treatment and taking a triptan medication for her migraines. She takes no other medications at this time.

Vital Signs:
B/P: 162/82

Temperature 98.6

Weight 234 lbs.

Respiratory rate: 16

Questions
1. What risk, if any, might the patient’s diabetes have on an increased risk of major CVD in this patient diagnosed with migraine with aura?

2. Are there any factors related to the patient’s recent visit to the emergency department and today’s vital signs that indicate a need to change the patient’s migraine medication and treatment plan? Do you make any outside referrals?

  • June 23, 2021
    Triptans should not be recommended
  • June 14, 2021
    Vasculopathology- would use a CGRP inhibitory ie. Emgality prophylaxis and prn CGRP such as Ubrelvy. No triptans.
  • June 13, 2021
    She should definitely be on a statin and an ARB because of her diabetes and CVD. Weight loss and strict glucose control should be discussed. She would also benefit from switching from the triptan to another migraine therapy, potentially preventive therapy bc of her persistent symptoms.
  • June 01, 2021
    B/P: 162/82 - is high and should be addressed. Healthy life style , weight reduction should be discussed. Aspirin, daily is good choice
  • June 01, 2021
    Triptans should be discontinued given history of CVD. I would consider cGRP inhibitors treatment. Statins should be considered
  • May 31, 2021
    Her diabetes definitely increases her risk of CVD through atherosclerosis. Based on her ED visit and vitals signs I would refer to a cardiologist and neurologist. Anti-CGRP and 81 mg aspirin.
  • May 31, 2021
    Her Diabetes as well as her hypertension play roles in her CVD. I would recommend a ,ASA 81 mg and no further triptans for treatment. I would consider a cGRP inhibitor.
  • May 17, 2021
    I would add cGRP, a glp-1 for diabetes in light of cod no further statins, may also benefit with botox,
  • May 17, 2021
    Diabetes is a risk factor for vascular disease, specifically small vessel disease. With her history of migraines, it can be difficult to differentiate between chronic migraines vs development of cerebral vascular disease.
    It would be important to educate the patient on understanding her baseline migraine symptoms, and warning signs of any new headache symptoms that would warrant emergency medical attention. I would also encourage good blood pressure management. Her blood pressure is too elevated currently. This also elevates her risk of stroke, aneurysm formation, etc.
  • May 14, 2021
    Ensure her DM management is optimized, along w use of statin therapy & ASA 81mg daily. In light of her multiple cardiac risk factors, she should no longer be on triptans.
    If her insurance allows, would consider cGRP inhibitor for her migraine
  • May 14, 2021
    Monitor diabetes
    Screen for neuro involvement
    Try CGRP
  • May 14, 2021
    Triptans can exacerbate CVd so switch to a cgrp inhibitor; a glp1 inhibitor for diabetes would also aid with weight loss; asa can be beneficial for CVd and migraine prevention; also needs a statin.
  • May 14, 2021
    *medication for blood pressure.
  • May 14, 2021
    Multiple conditions need to be addressed (weight, CVD, diabetes, blood pressure, and migraines). Semaglutide would help for her diabetes. Bempedoic acid for CVD and weight loss. Anti-CGRP for migraines.
  • May 14, 2021
    I would stop the triptans and prescribe Nurtex ODT.
  • May 14, 2021
    I would stop the Triptans due to CV risk. I would use Nurtec ODT as an abortive therapy and QOD as a prophylactic and Parenteral CGRP's ie. Emgality if successful. Full CV workup is necessary due to risk factors described. A daily ASA 81 mg is advisable.
  • May 14, 2021
    Triptan needs to be discontinued now that she has treatment needs to be started if migraines are frequent. Episodic treatment can be with cGRP inhibitors.BP and DM and Lipids need control too.
  • May 14, 2021
    Diabetes is definitely a risk factor for CVD. Would start statin and get CT. document that BP controlled before meds
  • May 14, 2021
    Diabetes is a risk factor in of itself for CVD. I would recommend a statin along with ASA and avoid triptans.
  • May 10, 2021
    Diabetes is a risk factor for CVD, independent of her migraine with aura. But I would now avoid triptans given that she has multiple CVD risk factors, cGRP inhibitors would be an option.