MKSAP: 36-year-old woman with a history of migraine

MKSAP: 36 year old woman with a history of migraineTest your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 36-year-old woman is evaluated in the office for a history of migraine, with and without aura, since age 16 years. She has an average of three attacks each month and consistently experiences an attack 2 days prior to menstruation; this headache is more difficult to treat than those not associated with menstruation. Although she typically obtains pain relief within 2 hours of taking sumatriptan, the headache recurs within 24 hours after each dose during the period of menstrual flow. Sumatriptan, orally as needed, is her only medication.

Results of physical examination are unremarkable.

Which of the following is the most appropriate perimenstrual treatment for this patient’s headaches?

A) Estrogen-progestin contraceptive pill
B) Mefenamic acid
C) Sumatriptan plus naproxen, orally
D) Sumatriptan, subcutaneously
E) Topiramate

MKSAP Answer and Critique

The correct answer is B) Mefenamic acid. This item is available to MKSAP 15 subscribers as item 3 in the Neurology section. More information about MKSAP 15 is available online.

This patient should be treated with mefenamic acid. She has migraine with aura, migraine without aura, and menstrually related migraine. Her menstrually related headaches are less responsive to acute therapy than are the non-menstrually related attacks, and headache recurs daily throughout menses. The best management for this patient is, therefore, the perimenstrual use of a prophylactic agent. There is evidence that supports the use of mefenamic acid for perimenstrual prophylaxis, with treatment starting 2 days prior to the onset of flow or 1 day prior to the expected onset of the headache and continuing for the duration of menstruation. In this patient, that would mean beginning 3 days before the onset of menstrual flow and continuing throughout menstruation.

The use of combined oral contraceptive therapy (estrogen plus progestin) is contraindicated in this woman because of her history of migraine with aura. Women with migraine with aura are at a twofold increased risk of ischemic stroke, ischemic myocardial infarction, and venous thromboembolism. The risk of stroke is increased further, up to eightfold, in women with migraine with aura who use combined oral contraceptive pills.

No evidence supports the oral use of either sumatriptan plus naproxen sodium or topiramate for the perimenstrual prophylaxis of menstrually related migraine. Similarly, there is no evidence supporting the subcutaneous use of sumatriptan in this setting. In fact, the higher recurrence rate with the subcutaneous formulation may prove counterproductive.

Key Point

  • Evidence supports the use of mefenamic acid for perimenstrual prophylaxis of menstrually related migraines, with treatment starting 2 days prior to the onset of flow or 1 day prior to the expected onset of the headache and continuing for the duration of menstruation.

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