A 22-year-old woman seeks advice for the treatment of headaches. The first of these headaches began at age 16, but their frequency has increased to 2 to 3 per month over the past year. The headaches are not preceded by an aura. The headaches are usually bilateral, are throbbing, and are so intense that she has to go home from work. Loud noise and physical activity make the pain more severe. Each headache lasts until the evening; she will awaken the next morning without pain or nausea, and will be able to return to work. She takes acetaminophen at the onset of the headache but without benefit. She is on no other medications including oral contraceptives. Neurological examination is benign.
What is the best step in the management of these headaches?
A. Topiramate starting at a dose of 25 mg twice dailyAlthough the classic migraine is unilateral and is preceded by an aura, many patients experience migraines without aura (formerly termed “common” migraines). This patient’s female gender, the onset of the headaches in adolescence, the severity of the pain, and the worsening with light, noise, or activity are all suggestive of migraine. Muscle contraction headaches are often bilateral but occur more frequently (often every afternoon), are less intense (rarely debilitating), and are usually relieved by simple analgesics. Medication overuse headaches are often bilateral but occur more frequently (usually daily); this patient’s occasional use of acetaminophen is insufficient to cause medication overuse headache. Space-occupying lesions can cause bilateral headaches, but the headaches occur more frequently, at increasing severity (as the lesion expands), often worsen at night or with Valsalva maneuver, and are usually associated with (sometimes subtle) focal abnormalities on neurological examination.
Triptans are very effective medications to abort migraines and are usually the first agents tried in patients either with or without aura. Parenteral or nasal triptans are favored if the patient needs rapid relief or if vomiting precludes the use of oral medications. It is often necessary to try two of three different agents to find which one works best for the individual patient. If the headaches occur frequently or are debilitating despite triptan treatment, prophylactic medications are called for. These medications are administered daily in order to prevent the migraines from occurring; they are ineffective if used at the onset of the headache. Beta-blockers, tricyclic antidepressants, and certain anticonvulsants (topiramate, valproate) are the usual prophylactic agents that are tried. Gabapentin is less effective. Narcotics such as hydrocodone are often less effective than triptans and carry the risk of habituation if used frequently.