What is the best treatment plan for a 43-year-old woman with migraines, type 2 diabetes, and obesity, experiencing worsening headaches and frequent use of sumatriptan and OTC analgesics?

Management of Worsening Migraines in a Patient with Type 2 Diabetes and Obesity

This patient requires immediate transition from acute medication overuse to a preventive migraine treatment regimen, with topiramate as the first-line preventive medication.

Assessment of Current Situation

The patient presents with clear signs of medication overuse headache (MOH), evidenced by:

• Increased headache frequency (from 1-2/week to 4/week)
• Frequent use of sumatriptan and OTC analgesics
• Pulsating pain behind right eye with photophobia and nausea
• Visual symptoms including blurry vision and possible blind spots

These symptoms, particularly the increased frequency and medication use, strongly suggest medication overuse headache superimposed on migraine 1.

Immediate Management Priorities

1. Discontinue medication overuse

   • Limit sumatriptan to fewer than 10 days/month 2
   • Limit OTC analgesics to fewer than 15 days/month 2
   • Educate patient about medication overuse headache

2. Implement headache diary

   • Document frequency, duration, intensity of headaches
   • Track medication use and efficacy
   • Identify potential triggers 1, 2

Preventive Treatment Plan

First-line Preventive Medication

Topiramate is recommended as the first-line preventive medication for this patient with the following considerations:

• Start at 25 mg daily and gradually increase to target dose of 100 mg/day (divided doses) 2
• Effective for both migraine prevention and potential weight loss benefit for this patient with obesity 2
• Monitor for side effects including paresthesias, cognitive slowing, and taste disturbances
• Allow 6-8 weeks at therapeutic dose to assess efficacy 2

Alternative Preventive Options (if topiramate is ineffective or not tolerated)

1. Propranolol (80-240 mg/day)

   • Monitor for effects on blood glucose in this diabetic patient
   • Contraindicated if patient has asthma or significant bradycardia

2. Amitriptyline (30-150 mg/day)

   • Start at low dose (10 mg) and titrate slowly
   • May help with sleep disturbances if present
   • Monitor for weight gain which could worsen obesity 2

3. Angiotensin receptor blockers

   • Candesartan or telmisartan may be considered if first-line options fail 1, 2

Acute Treatment Optimization

1. Optimize sumatriptan use

   • Limit to ≤9 days/month to prevent medication overuse 3
   • Consider switching to rizatriptan, which may have better efficacy-to-side-effect ratio 4
   • Educate on early treatment when pain is mild for better efficacy 3, 5

2. Alternative acute treatments

   • NSAIDs (naproxen 500-550 mg) for less severe attacks
   • Consider CGRP antagonists (gepants) if triptans contraindicated or ineffective 1

Non-Pharmacological Approaches

1. Lifestyle modifications

   • Regular physical activity appropriate for patient with obesity and diabetes
   • Regular sleep schedule
   • Stress management techniques 2

2. Behavioral interventions

   • Cognitive behavioral therapy
   • Relaxation training
   • Mindfulness-based treatment 1, 2

Special Considerations for This Patient

1. Diabetes management

   • Some preventive medications (particularly beta-blockers) may affect glycemic control
   • Monitor blood glucose more frequently when initiating new medications

2. Obesity considerations

   • Obesity is a risk factor for migraine chronification 6
   • Weight loss may improve migraine frequency and severity
   • Topiramate may assist with weight loss as a beneficial side effect

3. Visual symptoms

   • The patient's visual symptoms (blurry vision, blind spots) require careful evaluation
   • Consider ophthalmology referral to rule out diabetic retinopathy or other ocular conditions

Follow-up Plan

1. Schedule follow-up in 4 weeks to assess:

   • Medication tolerability
   • Progress with discontinuing medication overuse
   • Review of headache diary

2. At 8 weeks, evaluate preventive medication efficacy:

   • If <50% reduction in headache frequency, consider dose adjustment or alternative medication
   • If good response, continue current regimen and reassess in 3 months

Potential Pitfalls to Avoid

1. Continuing to treat with acute medications only

   • This will perpetuate the cycle of medication overuse headache

2. Failing to address comorbidities

   • Diabetes and obesity management are integral to migraine control

3. Inadequate duration of preventive treatment trial

   • Preventive medications require 6-8 weeks at therapeutic doses to demonstrate efficacy

4. Overlooking serious secondary causes

   • The patient's visual symptoms and worsening with bending down warrant consideration of secondary headache disorders