Possibly use an abortive Rxs, the goal of abortive treatment is to stop a migraine once it starts. Use of CGRP antagonists - rimegepant (Nurtec ODT) and ubrogepant (Ubrelvy) or CGRP inhibitors used to block the calcitonin gene-related peptide: atogepant (Qulipta), eptinezumab (Vyepti), erenumab (Aimovig), fremanezumab (Ajovy), galcanezumab (Emgality)

I would start her on aiMovie do to the number of headaches and the disruption of her life

If she is not opposed to injections, Aimovig is a good choice in the CGRP group. Qulypta is also good (it is the daily option and the same as Ubrelvy). Nurtec can be used every other day in this class also, but I worry about compliance with every other day dosing.

Her preventative therapy needs to be changed, most likely to a CRGP. see if she is open to injectable prevention medications. Need to change her abortive medication as well as it clearly isn't working. Find out her triggers, lifestyle changes, make sure she has had recent labs and brain imaging

Verify migraine diagnosis
Exclude hypertension by daily daily BP monitoring
Rule out sleep related issues
Basic labs B12 and sed rate and TFTs all ok
Hard to recommend without knowing what has been tried as preventive and abortive treatments

Verify Migraine diagnosis
BP measurement daily to exclude Hypertension as a trigger
Sleep history if any concerns of sleep apneas
Then basic labs
Hard to recommend unless we know what has been tried as preventive snd abortive treatmenrsc

I would treat with Aimovig due to number of migraines per month.

If these headaches are typical of her migraines MRI is not triggers,treat her stress,consider switching from topamax to elavil.

She should have a MRI/MRA of brain if not done within a year. Review all medication history including OTC, herbal meds, RX's. amitriptylline at bedtime for sleep and headache prophylaxis. I would order/recommend aimov monthly.

I would get MRI for progression of symptoms and look to other prophylactic treatment options such as amitriptyline or propranolol.

Few things:
1. She is 50 and having increase frequency of headaches so MRI of brain should be considered.
2. Increased use of abortive medications makes it highly likely that she is suffering from some sort of medication overuse headache.
3. Depending on medication use, if topiramate is the only medication used, she would not qualify for CRGP for prevention. She would have to fail TCA and/or beta blocker
4. Given comorbid anxiety, TCA may be a good trial to help with this as well.
5. She does not meet criteria for botox given migraines are 10 per month, needs to be 15+
6. Some have suggested nurtec daily - this is not indicated. Would be nurtec every other day. This is a great medication to help with medication overuse headaches. Probably wouldn't get covered for preventative use. Possibly for prn use - depends on how many abortive meds have failed.
7. In the end, need more information. MRI of the brain is indicated based on information. Change of meds indicated but not sure which since we don't have the history.

Need to make sure that she has not been suffering from Psychiatric disorder like major depression. Raising 3 kids is stressing and being menopausal with other emotional ailment can exacerbate her migraine. Beta Blocker can be added as well as abortive treatment for migraine as needed.

a few options. has she been on beta blocker? i wonder if her multiple headaches are several headaches or one headache over several days? ubrelvy is excellent for prn use on acute migraine, and may find using it early in onset may be useful at eliminating multiple days of headache. if truly needing both elimination of acute migraine and prevention both, would consider nurtec---though i do not have much experience with it.
the cg drugs for migraine are truly game changers

I agree that a brain MRI would be helpful. I would also consider switching to a cGRP agent. A different abortive such as intranasal Zomig could be helpful, as well as possible botox injections.

Thanks, All, for your wonderful input! One leitmotif has been the need for additional work-up. What additional work-up would you recommend, and how would this work-up specifically influence treatment decisions? Please feel free to contribute.,

There are many factors to be considered for treatment choices. It depends on the frequency and severity of her headaches, how disabling her headaches are, how she responded to prior treatment, and other medical conditions she may have. After further clinical evaluation, I would recommend Nurtec ODT for both abortive and preventive measures.

After reviewing the case above. I would start Magnesium and Melatonin at night. Start a CGRP. Once this is working if she has anxiety switch from Topamax to possible low dose SSRI or amitriptyline.

Either switch to alternative preventive medication such as TCA and/or Neurology eval for Botox or alternative preventive medication such as CGRPs. Sometimes treating underlying issues like sleep apnea will help too and may be worth screening for this with sleep study. Consider treating anxiety as well with counseling and/or medication as there may be interplay between these issues as well (Again, TCA or maybe Cymbalta).

After further evaluation, there are several new medications that may be very helpful. Topamax may cause cognitive issues and may no longer be helping. Would consider the CGRP preventatives and/or Botox new to reduce frequency and severity.

MRI brain and consider stress therapy or an SSRI or CGRP antagonist. May also consider a sleep study

Would keep a good log with severity and potential triggers and situations when it happens. This allows the treating MD to see patterns and how to avoid them.

Stop topamax,add Elavil at night and anti CGRP treatment-

I would use a CGRP monoclonal antibody preferably with quarterly dosing option

Depending on what has been tried already I would try changing her preventive regimen- such as metoprolol, valproic acid or aimovig. for abortive therapy I would try triptans and nasal triptan sprays. i would factor in that she has significant negative affect on her QOL with frequent headaches per month

A pain diary is useful to monitor the migraines & associated factors contributing to the headaches; monitor her medication use to assess whether she administers it consistent w/how it’s prescribed to maximize benefit; stress levels throughout the day (concerns regarding work satisfaction, relationships, etc); sleep patterns; exercise; dietary patterns; etc. This would aid in individualizing her care. Preventative care including relaxation, biofdbk, stress mngt/ CBT coping strategies, sleep hygiene, exercise, diet.
Curious whether migraines started at age 50 or have been present for longer.

Obviously, her current medications are not controlling her migraines. An anti-CGRP would be a good treatment choice for her. If this improves her absenteeism, then hopefully her stress will be reduced.

Stress reduction, MRI brain, lab work up , SSRI for anxiety can be considered

Life style changes and will consider antiCGRP !

CGRP antagonists! really would benefit from either injectable antiCGRP monthly or nurtec QOD for prevention, and also for abortive therapy ubrelvy/nurtec. these have been so well tolerated and effective.

Lifestyle modifications are also very important, obesity has been linked to chronic migraine, therefore it is important to work on a healthy lifestyle, including aerobic exercise that is linked to improvement in migraine and healthy diet. Determining her sleep hygeine is another important factor, sometimes is important to take a holistic approach and not just switch from one medication to another.

I will add CBT on this patient which will help solve a lot of her problems.

We can use CGRP antagonist for prevention and acute attack for this patient This patient also need to reduce stress and anxiolytic also.

As long as exam is normal, do not think imaging is necessary. A cGRP inhibitor is the next step since there is not a risk of pregnancy, either the injection or oral preventive.

Aimovig monthly and Nurtec

MRI Brain. Will try SSRI for anxiety and Emgality for migraine

MRI Brain and labs. If negative would try Emgality

After w/u MRI labs. Start Nurtec, Mg and B2

MRI, once negative, magnesium, B2, stress reduction(hard I understand), aimovig, if no relief botox

It appears patient is not responding well to topiramate, and It is affecting her life, will suggest Emgality, for once a month treatment , if reluctant to injection, will prescribe Nurtec Odt every other day for migraine prevention and can take nurtec prn for acute migrine attacks.

I would add Nurtec for daily use as it does not cause weight gain. If it worked well then I would discontinue Topamax. Add lexapro to help with stress and mc headaches.

After complete work up including MRI is found to negative…I would start a magnesium supplement and work toward decreasing stress levels and possibly add a mild sleep aid.

I would recommend baseline work up including labs and a MRI / MRA of the brain if not done. Will discontinue topamax as her BMI is 26 and she might lose weight on topamax. Will start Elavil at bedtime as this would alleviate her stress and give her a good night’s rest and prevent headaches. Will start aimovig once a month for headache prevention alongwith Nurtec ODT prn as an abortive therapy. I have seen very effective anti CGRP properties of ginger and if it works for her she can incorporate a small amount in her diet it could help.

Nortriptyline at bedtime to help with stress and migraine headache prophylaxis can be added.
Aimovig once a month can be added for reducing the migraine headaches.

Would recommend an MRI/MRA brain if not done within the past year. She may benefit from Nurtec as prophylaxis

Care for her children, her ability to work as well as her well being and stress