What is the next step in treatment for a patient with migraines with aura who is currently on Imitrex (sumatriptan)?

Next Steps in Treatment for Migraines with Aura After Sumatriptan

For patients with migraines with aura who are currently on sumatriptan, the next step in treatment should be initiating preventive therapy with topiramate, which is specifically recommended for migraine with aura by the American Headache Society. 1

Evaluation of Current Acute Treatment

Before initiating preventive therapy, ensure optimal use of sumatriptan:

• Verify proper dosing: Sumatriptan is available in 25mg, 50mg, and 100mg tablets, with 50mg or 100mg often providing better efficacy 2
• Timing of administration: Sumatriptan should be taken at headache onset, not during aura phase 2
• Maximum daily dose: No more than 200mg in a 24-hour period 2
• Treatment frequency: Safety not established for treating more than 4 headaches in a 30-day period 2

Preventive Treatment Algorithm

First-line preventive options for migraine with aura:

1. Topiramate (100 mg/day) - specifically recommended for migraine with aura 1

   • Titrate slowly to minimize side effects
   • Monitor for cognitive effects, paresthesias, and weight loss

2. Beta-blockers - if no contraindications exist:

   • Propranolol (80-240 mg/day)
   • Timolol (20-30 mg/day)
   • Use with caution in patients with asthma, diabetes, heart block, or bradycardia 1

3. Amitriptyline (30-150 mg/day) - particularly beneficial if patient has comorbid depression or sleep disturbances 1

Second-line options if first-line treatments fail:

• Divalproex sodium (500-1500 mg/day)
• Sodium valproate (800-1500 mg/day)
• Angiotensin receptor blockers (candesartan/telmisartan) 1

Third-line options (after failure of at least two preventives):

• CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab) 1
• OnabotulinumtoxinA (Botox) for chronic migraine 1

Special Considerations for Migraine with Aura

Risk factors requiring attention:

• Women with migraine with aura have significantly higher risk of ischemic stroke (RR 2.08) 1
• Risk further increases with:
  • Age <45 years (RR 3.65)
  • Smoking (RR 9.03)
  • Oral contraceptive use (RR 7.02) 1

Contraindications:

• Combined hormonal contraceptives with estrogens are contraindicated 1
• Hormone replacement therapy should be avoided 1

Non-Pharmacological Approaches

Incorporate these alongside pharmacological treatment:

• Maintain a headache diary to identify triggers 1
• Regular aerobic exercise (as effective as relaxation therapy or topiramate in some studies) 1
• Cognitive-behavioral therapy and biofeedback 1
• Consider oral magnesium supplementation (400-600mg daily) 1

When to Refer to a Specialist

Consider referral if:

• Failure of two or more preventive medication trials
• Uncertain diagnosis
• Complex comorbidities
• Need for advanced treatments like onabotulinumtoxinA 1

Common Pitfalls to Avoid

1. Treating during aura phase: Sumatriptan is not recommended during the aura phase but should be taken at headache onset 2
2. Medication overuse: Excessive use of acute medications (>2 days/week) can lead to medication overuse headache 1
3. Ignoring stroke risk: Failing to address modifiable stroke risk factors in patients with migraine with aura 1
4. Inadequate trial duration: Preventive medications should be evaluated after 2-3 months of use 1
5. Overlooking comorbidities: Selecting preventive therapy without considering other medical conditions 1

By following this algorithm, you can provide comprehensive care for patients with migraine with aura who have not achieved adequate control with sumatriptan alone.