What is the next step in management for a patient with migraine who does not respond to triptans and has hypertension?

Management of Migraine in Patients with Hypertension When Triptans Fail

For patients with migraine who don't respond to triptans and have hypertension (144/94 mmHg), candesartan is the recommended next treatment option as it effectively treats both conditions simultaneously. 1

Treatment Algorithm for Triptan-Resistant Migraine with Hypertension

First-Line Options

1. Candesartan (8-32 mg daily)

   • Dual benefit: Effectively treats both hypertension and migraine prophylaxis 2, 1
   • Particularly advantageous in patients with BP of 144/94 mmHg
   • Studies show significant improvement in Migraine Disability Assessment scores and blood pressure reduction 1
   • Can reduce both incidence and severity of migraine attacks

2. Beta-blockers (if candesartan is contraindicated)

   • Propranolol (80-240 mg daily) or Timolol (20-30 mg daily) 2
   • First-line preventive therapy recommended by American College of Physicians 2
   • Caution: May cause fatigue, dizziness; contraindicated in asthma, heart failure 3

Second-Line Options

1. Topiramate (25-100 mg daily)

   • Effective for migraine prevention 2
   • FDA-approved for migraine prophylaxis 3
   • Monitor for side effects: cognitive impairment, paresthesias, weight loss

2. Calcium Channel Blockers

   • Flunarizine is a first-line option for migraine prophylaxis 2
   • Note: Evidence for other calcium channel blockers is limited 3

3. Antidepressants

   • Amitriptyline (30-150 mg daily) 2
   • Venlafaxine (75-150 mg daily) - helpful for comorbid insomnia 2

Acute Treatment Options (When Triptans Fail)

1. NSAIDs

   • First-line for mild to moderate attacks 4
   • Caution with hypertension: may increase blood pressure
   • Monitor for GI and renal side effects 3

2. Gepants or Ditans

   • Second-line agents for moderate to severe attacks 4
   • Advantage: No vascular contraindications unlike triptans 4
   • Limitation: Cost may be prohibitive

Non-Pharmacologic Interventions

• Lifestyle modifications:

  • Regular sleep schedule
  • Regular meals to prevent hypoglycemia-triggered headaches
  • Moderate aerobic exercise
  • Stress management techniques
  • Adequate hydration 2

• Supplements with evidence:

  • Magnesium 400-600mg daily
  • Riboflavin (Vitamin B2) 400 mg daily
  • Coenzyme Q10 2

Monitoring and Follow-up

• Evaluate response after 6-8 weeks of therapy
• Goal: 50% reduction in headache frequency 2
• Monitor blood pressure regularly
• Consider referral to headache specialist if inadequate response after 2-3 months 2

Important Considerations

• Poor control of blood pressure may exacerbate migraine frequency and severity 5
• Avoid opioids and butalbital-containing medications unless other options have failed 4
• Consider specialist referral if two or more preventive medications fail 2

Caution

• Some antihypertensive medications can cause headache as a side effect 5
• Some migraine treatments may worsen hypertension 5
• Women with migraine with aura should avoid estrogen-containing contraceptives due to increased stroke risk 2