What to do next for a patient taking Ubrelvy (Ubrogepant) 50mg as needed (PRN) and Amitriptyline 10mg nightly, but experiencing increased migraine frequency, with 3 episodes in one week?

Management of Increasing Migraine Frequency in a Patient on Ubrelvy and Amitriptyline

For a patient experiencing increased migraine frequency (3 episodes in one week) while on Ubrelvy 50mg PRN and Amitriptyline 10mg nightly, the recommended next step is to increase the amitriptyline dose to 30-100mg daily while maintaining the current acute treatment regimen. 1

Current Treatment Assessment

The patient is currently on:

• Ubrelvy (ubrogepant) 50mg PRN for acute treatment
• Amitriptyline 10mg nightly for prevention

Issues with Current Regimen:

• Amitriptyline dose is subtherapeutic for migraine prevention (therapeutic range is 30-150mg/day) 1, 2
• Increased migraine frequency (3 in one week) indicates inadequate prevention

Step-by-Step Management Approach

1. Optimize Preventive Therapy

• Increase amitriptyline dose gradually from 10mg to therapeutic range (30-100mg)
  • Start with 25mg nightly for 1 week, then increase by 10-25mg weekly as tolerated
  • Target dose: 50-75mg nightly 1, 2
  • Monitor for side effects: drowsiness, dry mouth, constipation, weight gain

2. Maintain Current Acute Treatment

• Continue Ubrelvy 50mg PRN for acute attacks
• Ensure proper usage:
  • Take at onset of migraine
  • May take second dose after 2 hours if needed (maximum 200mg/24 hours) 3
  • Limit to ≤8 migraines in a 30-day period 3
  • Avoid using >10 days/month to prevent medication overuse headache 1

3. If Inadequate Response After 6-8 Weeks

Consider these options based on treatment algorithm:

Option A: Switch Preventive Medication

• Topiramate 50-100mg daily 1
• Propranolol 80-160mg daily 1
• Candesartan 16-32mg daily 1

Option B: Add NSAID to Acute Treatment

• Add NSAID (naproxen 500mg or ibuprofen 600mg) to Ubrelvy for acute attacks 4
• This combination may provide better pain relief than Ubrelvy alone

Option C: Consider CGRP Monoclonal Antibodies

• If multiple preventives fail, consider erenumab or fremanezumab 1

Important Considerations

Medication Overuse Risk

• Limit Ubrelvy to ≤10 days/month to prevent medication overuse headache 4, 1
• Educate patient on early treatment of attacks to improve efficacy 4

Lifestyle Modifications

• Emphasize importance of:
  • Regular sleep schedule
  • Hydration
  • Regular meals
  • Stress management
  • Regular physical activity
  • Identifying and avoiding triggers 4, 1

Monitoring

• Use headache diary to track:
  • Frequency and severity of attacks
  • Medication use and efficacy
  • Potential triggers
  • Response to preventive therapy

Pitfalls to Avoid

1. Not optimizing current medications before switching

   • Amitriptyline at 10mg is subtherapeutic; doses of 30-100mg are needed for migraine prevention 1, 2

2. Overusing acute medications

   • Using Ubrelvy >10 days/month can lead to medication overuse headache 4, 1

3. Ignoring non-pharmacological approaches

   • Cognitive behavioral therapy, relaxation techniques, and regular exercise have proven efficacy 1, 5

4. Failing to recognize treatment failure

   • If no improvement after 6-8 weeks of optimized therapy, switch to alternative preventive medication 1

By following this approach, focusing first on optimizing the preventive medication dose while maintaining appropriate acute treatment, the patient has the best chance of reducing migraine frequency and improving quality of life.