What should Irina do next for her persistent headache symptoms?

Management of Persistent Headache Symptoms

For Irina's persistent headache symptoms, she should be referred to a specialist for evaluation of chronic migraine and initiation of preventive medication therapy, with topiramate as the first-line option due to its proven efficacy in chronic migraine. 1

Assessment of Headache Pattern

• Determine if Irina is experiencing ≥15 headache days per month for more than 3 months, with migrainous features present on ≥8 days per month, which would classify as chronic migraine 1
• Evaluate for medication overuse headache (MOH), which can mimic chronic migraine:
  • Use of simple analgesics on >15 days/month
  • Use of triptans, opioids, or combination medications on >10 days/month for >3 months 1
• Assess for comorbidities that may influence treatment choice:
  • Depression, anxiety, sleep disturbances
  • Obesity (may favor topiramate)
  • Cardiovascular risk factors 1

Immediate Management Steps

1. Rule out medication overuse headache:

   • If present, withdraw overused medications 1
   • Non-opioids and triptans can be stopped abruptly or weaned within a month
   • Opioids should be gradually withdrawn 1

2. Acute treatment optimization:

   • For mild-moderate attacks: NSAIDs (ibuprofen 400-800mg, naproxen sodium 275-550mg) 1
   • For moderate-severe attacks: Triptans (avoid if cardiovascular contraindications) 1, 2
   • Limit Fioricet (butalbital-acetaminophen-caffeine) to no more than twice per week, maximum 20 capsules per month 3
   • Consider antiemetics if nausea is present (metoclopramide 10mg) 1

3. Initiate preventive therapy:

   • Topiramate is first-line for chronic migraine with proven efficacy in randomized controlled trials 1
   • Starting dose: 25mg daily, gradually titrate to 100mg daily (divided doses) 1
   • Warn about side effects: paresthesia, cognitive slowing, weight loss, kidney stones 1

Follow-up Plan

• Schedule follow-up in 4-6 weeks to assess response
• Use headache diary to track frequency, severity, and medication use
• If inadequate response to topiramate after 2-3 months at optimal dose:
  • Consider referral for onabotulinumtoxinA or CGRP monoclonal antibodies 1
  • These are typically reserved for patients who have failed at least two preventive medications 1

Lifestyle Modifications

• Regular sleep schedule
• Regular meals and adequate hydration
• Moderate exercise program
• Stress management techniques (mindfulness, cognitive-behavioral therapy) 1
• Identify and avoid personal triggers

Common Pitfalls to Avoid

• Failure to recognize chronic migraine: Only 20% of patients who meet criteria are properly diagnosed 1
• Overuse of acute medications: Can perpetuate headache cycle and prevent effectiveness of preventives 1
• Inadequate dosing of preventives: Effective doses of topiramate for chronic migraine are typically 100mg/day 1
• Premature discontinuation: Preventive medications may take 2-3 months to show full benefit 1
• Ignoring comorbidities: Depression, anxiety, and sleep disorders can exacerbate headaches and should be addressed 1

Special Considerations

• If Irina has obesity, topiramate may be particularly beneficial due to its association with weight loss 1
• If she has depression or sleep disturbances, amitriptyline might be considered, though evidence for chronic migraine is less robust than for topiramate 1
• Avoid opioids for headache management due to risk of medication overuse and dependence 1

By following this structured approach, Irina's persistent headache symptoms can be appropriately managed with the goal of reducing headache frequency, severity, and associated disability.