MKSAP: 30-year-old woman is evaluated for difficult-to-treat migraine

Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 30-year-old woman is evaluated for difficult-to-treat migraine. She has had severe headaches, usually on the first day of menses, since menarche. The pain is hemicranial, pulsatile, and associated with severe nausea and vomiting but no aura. She frequently awakens with the attack already in progress. Ibuprofen was helpful in controlling migraine pain during her teenage years and early 20s but was replaced 5 years ago by oral eletriptan after the pain was no longer controlled; this drug now also is ineffective in relieving symptoms. A trial of oral frovatriptan for menstrual migraine relief also has been unsuccessful. The patient reports receiving intravenous dihydroergotamine and magnesium at an urgent care facility twice in the past 3 months as treatment of refractory headaches.

On physical examination, blood pressure is 98/60 mm Hg and pulse rate is 72/min. All other physical examination findings, including those from a neurologic examination, are normal.

Which of the following is the most appropriate next step in treatment?

A: Butalbital
B: Hydrocodone
C: Naproxen
D: Orally dissolvable rizatriptan
E: Subcutaneous sumatriptan

MKSAP Answer and Critique

The correct answer is E: Subcutaneous sumatriptan.

The patient should be treated with subcutaneous sumatriptan for migraine without aura. She no longer responds to NSAIDs and oral triptans. The headaches are associated with emesis, and she is awakening with attacks. Migraine episodes have been so severe that she has visited an urgent care facility recently for parenteral treatment of refractory migraine. Self-administered injectable migraine medications would be of value for this patient. Although nasal spray options exist for several acute medications, they are less potent than their injectable counterparts. According to guidelines, no first-line agent for acute migraine treatment is available in suppository form.

Neither butalbital compounds nor opioids (such as hydrocodone) are recommended as first-line treatments of recurrent headache disorders. Little evidence of benefit in acute migraine exists for either class of drugs, and both contribute to an increased future risk of transformation into chronic migraine, compared with first-line agents.

Evidence supports the use of naproxen in the management of acute migraine, and the drug is listed by evidence-based guidelines as first-line therapy. In the setting of migraine that occurs upon awakening or with vomiting, however, it is unlikely to be beneficial, especially in a patient who has not responded to another NSAID or oral triptan.

The orally dissolvable versions of rizatriptan and zolmitriptan require gastrointestinal absorption and thus should not be used in the setting of migraine with vomiting.

Key Point

  • Self-administered subcutaneous sumatriptan is appropriate as therapy for migraine without aura in patients not responding to NSAIDs or oral triptans, especially those with vomiting.

This content is excerpted from MKSAP 17 with permission from the American College of Physicians (ACP). Use is restricted in the same manner as that defined in the MKSAP 16 Digital license agreement. This material should never be used as a substitute for clinical judgment and does not represent an official position of ACP. All content is licensed to on an “AS IS” basis without any warranty of any nature. The publisher, ACP, shall not be liable for any damage or loss of any kind arising out of or resulting from use of content, regardless of whether such liability is based in tort, contract or otherwise.

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