What is the next treatment step for a 40-year-old patient with menstrual-related migraines that have worsened despite trying Bisoprolol, Amitriptyline, and a Triptan?

From the Guidelines

For a 40-year-old patient with worsening menstrual-related migraines despite trials of bisoprolol, amitriptyline, and a triptan, the next recommended treatment step would be to consider hormonal management strategies, specifically continuous combined hormonal contraception (CHC) or perimenstrual prevention with naproxen, as these approaches have shown efficacy in preventing menstrual migraines 1. The patient's history of worsening migraines, particularly around the time of her period, suggests a strong hormonal component to her migraines.

• Continuous combined hormonal contraception (CHC) such as a combined oral contraceptive pill taken continuously without the hormone-free interval could be tried, as it maintains stable estrogen levels, preventing the estrogen withdrawal that often triggers menstrual migraines.
• Alternatively, if CHCs are contraindicated, perimenstrual prevention with naproxen 500 mg twice daily starting 2 days before expected menses and continuing for 5-7 days could be effective, as naproxen has been shown to be effective in preventing menstrual migraines 1.
• Another option is to add a CGRP monoclonal antibody such as erenumab (70-140 mg monthly) as preventive therapy, which specifically targets the migraine pathway and can be particularly effective for hormonal migraines, as suggested by the most recent and highest quality study 1. These approaches work by addressing the hormonal trigger directly or by targeting the neuroinflammatory pathways involved in migraine pathophysiology that are particularly sensitive to estrogen fluctuations during the menstrual cycle.
• The choice of treatment should be individualized based on the patient's medical history, preferences, and potential contraindications, and the patient should be closely monitored for efficacy and potential side effects.
• It is also important to note that the patient's previous trials of bisoprolol, amitriptyline, and a triptan were not effective, and therefore, these options should not be reconsidered unless there are significant changes in the patient's clinical presentation or medical history 1.

From the Research

Treatment Options for Menstrual-Related Migraines

The patient's experience with worsening migraines despite trying Bisoprolol, Amitriptyline, and a Triptan suggests the need for alternative treatment approaches. Considering the menstrual-related nature of the migraines, the following options could be explored:

• Topiramate: A study published in 2011 2 found that topiramate is effective in reducing the frequency of perimenstrual migraines. The study showed a mean reduction of 2.66 migraine days per month, with similar reductions in migraines during and outside the perimenstrual period.
• Desogestrel-only contraception: Research from 2013 3 suggests that desogestrel 75 µg may have a positive impact on migraine frequency, intensity, and use of acute medication. The study found significant reductions in days with migraine, headache intensity, and medication use.
• Alternative acute therapies: A commentary from 2008 4 suggests that effervescent aspirin could be considered as a first-line treatment for migraine, given its efficacy and lower cost compared to triptans.

Considerations for Treatment

When selecting the next treatment step, the following factors should be considered:

• The patient's experience with previous treatments, including the lack of benefit from Amitriptyline and the worsening of migraines with the Triptan
• The menstrual-related nature of the migraines, which may require hormonal or preventive therapies
• The potential benefits and risks of each treatment option, including the efficacy and tolerability of topiramate and desogestrel-only contraception

Potential Next Steps

Based on the available evidence, potential next steps for the patient could include:

• Initiating topiramate as a preventive therapy to reduce the frequency of perimenstrual migraines
• Considering desogestrel-only contraception as a potential treatment option to reduce migraine frequency and intensity
• Exploring alternative acute therapies, such as effervescent aspirin, for the treatment of migraines
• Continuing to monitor the patient's response to treatment and adjusting the treatment plan as needed to achieve optimal results.