What treatment options are available for a 42-year-old female with a 4-year history of migraines, now experiencing increased frequency of 6 attacks per month, previously managed with sumatriptan (generic name: sumatriptan) and over-the-counter (OTC) ibuprofen or Excedrin Migraine (generic name: acetaminophen, aspirin, and caffeine)?

Treatment Options for Increased Migraine Frequency

Daisy should start preventive migraine therapy immediately due to her increased frequency of 6 migraine attacks per month, which is interfering with her ability to operate her bakery. 1

Assessment of Current Situation

Daisy's case presents several important clinical considerations:

• Increased frequency from 2 to 6 migraine attacks per month
• Effective acute treatment with sumatriptan
• Use of OTC medications (ibuprofen, Excedrin Migraine) for lesser headaches
• Functional impairment affecting her livelihood

Treatment Algorithm

Step 1: Initiate Preventive Therapy

Preventive therapy is clearly indicated based on:

• Frequency of 6 attacks per month (exceeds threshold of 2-4 attacks per month)
• Functional disability affecting her work
• Risk of medication overuse headache from increasing use of acute medications 1

Step 2: First-line Preventive Medication Options

Based on the strongest evidence, choose one of these first-line preventive medications:

• Beta-blockers: Propranolol (80-240 mg/day) or metoprolol (50-200 mg/day)
• Anticonvulsants: Topiramate (25-100 mg/day) or divalproex sodium (500-1000 mg/day)

These medications have the best documented efficacy for migraine prevention 2, 3.

Step 3: Optimize Acute Treatment

While continuing effective sumatriptan:

• Take early in attack while pain is still mild 4
• Consider combination therapy with naproxen for better sustained pain relief 4
• Limit sumatriptan to no more than 9 days per month to prevent medication overuse headache 1
• Limit OTC medications to no more than 14 days per month 1

Important Considerations

Medication Overuse Risk

Daisy's increased use of both sumatriptan and OTC medications puts her at risk for medication overuse headache:

• Triptans should be limited to no more than 9 days per month
• NSAIDs should be limited to no more than 14 days per month
• Combination analgesics containing caffeine (like Excedrin Migraine) should be used cautiously 1

Cardiovascular Risk Assessment

Before continuing sumatriptan, assess for cardiovascular risk factors:

• Smoking status
• Blood pressure
• Cholesterol levels
• Family history of heart disease
• Diabetes
• Obesity 4, 5

If cardiovascular risk factors are present, consider alternative acute treatments or closer monitoring.

Lifestyle Modifications

Implement these alongside pharmacological treatment:

• Identify and avoid trigger factors
• Maintain regular sleep schedule
• Regular physical activity
• Stress management techniques
• Consider magnesium or riboflavin supplementation 1, 2

Follow-up Plan

• Schedule follow-up in 4-6 weeks to assess effectiveness of preventive therapy
• Use headache diary to track frequency, severity, and medication use
• Adjust preventive medication dose if needed or switch to alternative if ineffective
• Consider referral to neurologist or headache specialist if no improvement after trials of 2-3 preventive medications 1

Common Pitfalls to Avoid

1. Delaying preventive therapy when clearly indicated by frequency and disability
2. Focusing only on acute treatment without addressing prevention
3. Not monitoring for medication overuse headache
4. Failing to address lifestyle factors that may contribute to migraine
5. Not recognizing when to refer to a specialist for refractory cases

Preventive therapy is essential for Daisy to reduce her migraine frequency, prevent progression to chronic migraine, and improve her quality of life and ability to work 6.