doc_clotaire
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A 21-year-old woman comes to the office because of 6 months of intermittent headaches. She reports having headaches in the past, but these are much more severe. The headaches are described as throbbing, unilateral, with associated photophobia. They are typically noticed around the time of her menses but are also exacerbated during stressful times such as her midterm exams. There is not an aura preceding any of these headaches. She has tried 200 mg of ibuprofen with minimal relief. Currently she is headache free. Physical examination is unremarkable. Her neurological examination is non-focal. The most appropriate pharmacotherapy to treat this patient's headaches is
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[fullfont size="3"] A. amitriptyline
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[fullfont size="3"] B. dihydroergotamine
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[fullfont size="3"] C. indomethacin
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[fullfont size="3"] D. sumatriptan
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[fullfont size="3"] E. verapamil
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| DrVirgo
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Migraine Headache management.
For Mild: NSAIDS
Moderate-Severe: Sumatriptan (Contraind if CV disease)
Prophylaxis: Ergot alkaloid for pt.s with >3HA/month
D. sumatriptan ---to treat the HA
B. dihydroergotamine --to prevent future HA
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| doc_clotaire
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so what s your answer buddy ?
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| dr.wad
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sumatriptan and ergotamine both are used to treat the attacks.
amitriptyline and verapamil are used for prophylaxis.
i dont know which one is the correct ....and why ??
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| farnsworth
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my answer would be D, sumatriptan has a favorable side effect profile over ergotamine
For prophylaxis: beta receptorblockers or Ca++ antagonists (or valproate)
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| dr.wad
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farnsworth wrote:
my answer would be D, sumatriptan has a favorable side effect profile over ergotamine
For prophylaxis: beta receptorblockers or Ca++ antagonists (or valproate)
could u plz explain ......
the pt is headache free ...
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| farnsworth
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dr wad: you are right, the patient is currently headache free. I missed that. For prevention of migraine attacks, TCAs are more efficient than Ca++ channel blocking agents.
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| DrVirgo
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I'll go with D. sumatriptan
but something tells me this is a trick question...
Is it a Step 3 question from Goljan? 
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| jean robert
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Good intuition Dr Virgo , It is indeed a tricky question .I would not post it it was that easy 
Explanation:
The correct answer is C. NSAIDs are first-line therapy against migraine headaches. Even if a patient tells you that that they have tried NSAIDs without relief, you must first inquire if they have taken an appropriate dose prior to providing other therapy. For example, no headache relief with 200 mg of ibuprofen is not a treatment failure. First-line therapy for migraines is a trial of moderate to high-dose NSAIDs along with environmental controls such as placing the patient in a darkened, quiet room until symptoms resolve. All of the other agents mentioned below can be effective for migraines but they are definitely second-line agents or used for migraine prophylaxis.
Amitriptyline (choice A) is a tricyclic antidepressant, which has a role in prophylaxis of tension and migraine headache but is not useful in acute treatment.
Dihydroergotamine (choice B) is a potent vasoconstrictor with less peripheral vasoconstriction than the above. Its advantages are that it comes in IV/IM or intranasal form. It should also be used with caution in patients with coronary artery or peripheral vascular disease.
Sumatriptan (choice D) is another potent vasoconstrictor which can be delivered intranasally or subcutaneously. It should not be used in patients with CAD or uncontrolled hypertension. It acts by binding to 5-HT1 receptors selectively.
Verapamil (choice E) is a calcium channel blocker which can be used as prophylactic treatment. They have been shown to decrease the frequency of migraines but they do not affect the severity or duration of attacks.
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| doc_clotaire
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Sorry folks .......that was me with the correct answer .
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| shahnaz.r
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I'd go for A [ Amitryptiline]
Migrain prophylaxis:
Anticonvulsant: divalproex, Topiramate.
TCA: amitryptiline, nortryptiline,
Beta-Blokers: Propranolol, timolol
5-HT antagonist: methylsergide[ not used usually due to it's S/E profile(valvular and retroperitoneal fibrosis)]
Note: A prophylactic agent is recommended only if a patient has more than 3 attacks per month.
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| DrVirgo
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jean robert wrote:
For example, no headache relief with 200 mg of ibuprofen is not a treatment failure. First-line therapy for migraines is a trial of moderate to high-dose NSAIDs along with environmental controls such as placing the patient in a darkened, quiet room until symptoms resolve.
Ok, that makes sense... But when would we consider "treatment failure" and move on to another medication?
And another question...
According to Kaplan, NSAIDS are the treatment for "mild" migraines, and Sumatriptan is the drug of choice for "moderate to severe" migraine. How can we tell the difference between mild, mod. and severe? Thanks.
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