From the Guidelines
For a 44-year-old female with migraines and a history of bariatric surgery, the most effective treatment approach would be to use medications that bypass gastrointestinal absorption issues, such as injectable CGRP antagonists like erenumab, fremanezumab, or galcanezumab, as recommended by the 2023 U.S. Department of Veterans Affairs and U.S. Department of Defense clinical practice guideline for the management of headache 1.
Key Considerations
- The patient's history of bariatric surgery necessitates the use of medications that do not rely on normal gastrointestinal anatomy for absorption.
- Injectable CGRP antagonists, such as erenumab, fremanezumab, or galcanezumab, are strongly recommended for the prevention of episodic or chronic migraine 1.
- These medications have been shown to be effective in reducing migraine frequency and severity, and their injectable formulation bypasses potential absorption issues related to bariatric surgery.
Treatment Recommendations
- Erenumab, fremanezumab, or galcanezumab should be considered as first-line preventive therapy, with dosing regimens as follows: erenumab 70-140mg, fremanezumab 225mg, or galcanezumab 120mg after a 240mg loading dose 1.
- For acute treatment, liquid or rapidly dissolving formulations such as sumatriptan nasal spray (5-20mg per dose) or rizatriptan orally disintegrating tablets (5-10mg) may be effective.
- Supplementing with vitamin B12 (1000mcg daily), vitamin D (1000-2000 IU daily), and calcium (1200-1500mg daily) is crucial to address potential micronutrient deficiencies common after bariatric surgery.
Non-Pharmacological Approaches
- Regular hydration, sleep patterns, stress management techniques, and trigger avoidance should be incorporated into the treatment plan to optimize migraine management.
- These non-pharmacological approaches can help reduce migraine frequency and severity, and improve overall quality of life.
From the FDA Drug Label
The efficacy of sumatriptan tablets in the acute treatment of migraine headaches was demonstrated in 3, randomized, double-blind, placebo-controlled trials. Patients enrolled in these 3 trials were predominately female (87%) and Caucasian (97%), with a mean age of 40 years (range of 18 to 65 years).
The treatment for a 44-year-old female with migraines is sumatriptan tablets. However, there is no information in the provided drug label about the safety or efficacy of sumatriptan in patients with a history of bariatric (weight loss) surgery. Therefore, a conservative clinical decision would be to exercise caution when prescribing sumatriptan to this patient, and consider consulting the patient's surgeon or a specialist for further guidance 2.
From the Research
Treatment for Migraines
The treatment for a 44-year-old female with migraines and a history of bariatric (weight loss) surgery involves several options, including:
- Acute migraine treatment with acetaminophen, nonsteroidal anti-inflammatory drugs, and combination products that include caffeine 3
- Migraine-specific treatments, such as triptans (5-HT1B/D agonists), which can eliminate pain in 20% to 30% of patients by 2 hours, but may have adverse effects such as transient flushing, tightness, or tingling in the upper body 3
- Gepants, antagonists to receptors for the inflammatory neuropeptide calcitonin gene-related peptide, such as rimegepant or ubrogepant, which can eliminate headache symptoms for 2 hours in 20% of patients but may have adverse effects of nausea and dry mouth 3
- A 5-HT1F agonist, lasmiditan, which appears safe in patients with cardiovascular risk factors 3
Considerations for Patients with Cardiovascular Disease
For patients with migraines and cardiovascular disease, certain medications may be contraindicated due to possible coronary side effects 4. For example:
- Triptans may be contraindicated in patients with cardiovascular disease due to their vasoconstrictive properties 3, 4
- Other medications, such as beta-blockers, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, antiepileptics, and antidepressants, may be used for preventative treatment of migraines in patients with cardiovascular disease 4
Importance of Individualized Treatment
It is essential to individualize treatment for each patient based on their specific needs and medical history. In the case of a 44-year-old female with migraines and a history of bariatric surgery, the treatment plan should take into account her unique medical history and any potential interactions with other medications she may be taking 5.