What prescription drugs and remedies can help lessen the frequency and pain of chronic migraines triggered by computer use, loud noises, flashing lights, and snowstorms in a patient with a history of concussion and occipital nerve release and ablation surgeries?

Management of Chronic Migraines Following Concussion and Occipital Nerve Surgeries

For chronic migraines triggered by computer use, loud noises, flashing lights, and weather changes, a combination of preventive medications (first-line: propranolol, topiramate, amitriptyline, or divalproex sodium) and acute treatments (NSAIDs followed by triptans) is recommended, along with trigger avoidance and lifestyle modifications.

Acute Treatment Options

First-Line Treatments

• NSAIDs should be used as first-line treatment for mild to moderate migraine attacks 1:
  • Aspirin (650-1000 mg)
  • Ibuprofen (400-800 mg)
  • Naproxen sodium (275-550 mg)
  • Combination of acetaminophen-aspirin-caffeine

Second-Line Treatments

• Triptans should be used when NSAIDs are ineffective 1:
  • Sumatriptan (oral, subcutaneous)
  • Rizatriptan
  • Zolmitriptan
  • Naratriptan
  • Eletriptan (20-40 mg) 2

For Attacks with Nausea/Vomiting

• Use non-oral routes of administration 1
• Add antiemetic medications:
  • Metoclopramide (10 mg)
  • Prochlorperazine

Important Cautions

• Limit acute medications to no more than twice weekly to prevent medication-overuse headache 1
• Avoid opioids, barbiturates, and ergot alkaloids due to risk of dependency and questionable efficacy 1

Preventive Treatment

Given your wife's history of chronic migraines following concussion and occipital nerve procedures, preventive therapy is strongly indicated.

Indications for Preventive Therapy (your wife meets several):

• Two or more migraine attacks per month with disability lasting 3+ days
• Failure of acute treatments
• Use of acute medications more than twice weekly
• Presence of triggers that are difficult to avoid 1

First-Line Preventive Medications

1. Beta-blockers:

   • Propranolol (80-240 mg/day)
   • Timolol (20-30 mg/day)

2. Anticonvulsants:

   • Topiramate (50-100 mg/day) - particularly effective for migraines with sensory triggers
   • Divalproex sodium (500-1500 mg/day) - contraindicated in women of childbearing potential

3. Tricyclic antidepressants:

   • Amitriptyline (30-150 mg/day) - especially effective for patients with sleep disturbances

Second-Line Preventive Medications

• Flunarizine (5-10 mg/day)
• Venlafaxine (extended-release)

Third-Line Preventive Options

• OnabotulinumtoxinA (155-195 units every 12 weeks) - particularly effective for chronic migraine
• CGRP monoclonal antibodies (erenumab, fremanezumab, eptinezumab) 1

Non-Pharmacological Approaches

Given your wife's specific triggers (computer use, loud noises, flashing lights, snowstorms), these non-pharmacological approaches are particularly important:

1. Trigger identification and management 3:

   • Use blue light filtering glasses for computer work
   • Take regular breaks from screen time (20-20-20 rule: every 20 minutes, look at something 20 feet away for 20 seconds)
   • Use noise-canceling headphones in loud environments
   • Install anti-glare screens on computers
   • Use FL-41 tinted glasses for light sensitivity

2. Lifestyle modifications:

   • Maintain regular sleep patterns
   • Stay hydrated
   • Regular, moderate exercise
   • Stress management techniques

3. Dietary supplements with some evidence of efficacy:

   • Magnesium (400-600 mg daily)
   • Riboflavin (400 mg daily)
   • Coenzyme Q10 (100-300 mg daily)

4. Behavioral treatments:

   • Biofeedback
   • Cognitive behavioral therapy
   • Relaxation techniques

Monitoring and Follow-up

• Use a headache diary to track frequency, severity, duration, and triggers
• Evaluate response to preventive medications after 2-3 months of consistent use
• Assess effectiveness of acute medications using the Migraine Treatment Optimization Questionnaire (mTOQ-4) 1

Special Considerations for Post-Concussion and Post-Surgical Patients

Your wife's history of concussion and occipital nerve surgeries requires special attention:

• The occipital nerve procedures may have altered the pain pathways, potentially making some treatments more or less effective
• Post-concussion syndrome can complicate migraine management and may require more aggressive preventive strategies
• Consider consultation with a headache specialist or neurologist with expertise in post-traumatic headache

Remember that preventive medications must be given at therapeutic doses for at least 6-8 weeks before determining effectiveness 4. Combining pharmacological and non-pharmacological approaches is more effective than using either approach alone 3.