How to manage migraines in a patient with chronic uncontrolled hypertension taking lisinopril (angiotensin-converting enzyme inhibitor) 10 mg daily and metoprolol (beta blocker) 25 mg twice a day (bid)?

Management of Migraine in a Patient with Chronic Uncontrolled Hypertension

For a patient with chronic uncontrolled hypertension and migraine, topiramate is the recommended first-line prophylactic treatment, as it effectively prevents migraines without exacerbating hypertension. 1

Assessment of Current Hypertension Management

• The patient's current antihypertensive regimen (lisinopril 10 mg daily and metoprolol 25 mg BID) is suboptimal, as evidenced by continued uncontrolled hypertension 1
• Metoprolol's target dose for hypertension is 200 mg daily, significantly higher than the patient's current dose of 25 mg BID 1
• Lisinopril's target dose for hypertension ranges from 20-40 mg daily, higher than the current 10 mg dose 1

Migraine Treatment Considerations with Uncontrolled Hypertension

Acute Treatment Options

• Triptans are contraindicated in patients with uncontrolled hypertension due to their vasoconstrictive properties 1
• NSAIDs should be used cautiously as they may interfere with antihypertensive medications and raise blood pressure 2, 3
• Dihydroergotamine (DHE) intranasal formulation is a safer option for acute treatment in this patient 1
• Antiemetics such as metoclopramide or prochlorperazine can be effective for both headache pain and associated nausea 3

Prophylactic Treatment Options

• Topiramate (25-200 mg daily) is recommended as first-line prophylactic therapy as it:

  • Has established efficacy in chronic migraine with Level A evidence 1
  • Does not adversely affect blood pressure 1
  • Has demonstrated efficacy in double-blind, placebo-controlled trials 1

• Alternative prophylactic options include:

  • Increasing the current metoprolol dose to target range (200 mg daily) to address both hypertension and migraine 1, 4
  • Candesartan (an ARB) which has evidence for migraine prophylaxis and blood pressure control 5, 6
  • Amitriptyline (30-150 mg daily) which has evidence for efficacy in migraine but may cause cardiac side effects 1

Treatment Algorithm

1. Optimize current antihypertensive therapy:

   • Increase metoprolol to target dose of 200 mg daily (gradually titrate) 1
   • Increase lisinopril to 20-40 mg daily 1
   • Consider adding a third agent such as a diuretic if BP remains uncontrolled 1

2. Initiate migraine prophylaxis:

   • Start topiramate at 25 mg daily and gradually titrate to 100 mg daily (divided doses) 1
   • Monitor for side effects including cognitive impairment, paresthesia, and weight loss 1

3. For acute migraine attacks:

   • Use dihydroergotamine intranasal formulation 1, 3
   • Consider antiemetics for associated symptoms 3
   • Avoid triptans until hypertension is controlled 1

4. Non-pharmacological approaches:

   • Implement relaxation techniques, biofeedback, and cognitive behavioral therapy 1
   • Encourage regular exercise which benefits both migraine and hypertension 1
   • Maintain headache diary to identify triggers 1

Important Considerations and Pitfalls

• Monitor for medication overuse headache by limiting acute medications to fewer than 15 days/month for simple analgesics and fewer than 10 days/month for triptans 1
• Avoid combination therapy with multiple beta-blockers as this may lead to excessive bradycardia or hypotension 7
• Be aware that some migraine preventive medications (such as verapamil) may interact with the patient's current antihypertensive regimen 1
• Consider the patient's weight when selecting medications, as some agents like topiramate cause weight loss while others like amitriptyline may cause weight gain 1
• Establish realistic expectations with the patient, as prophylactic benefits may take 2-3 months to become apparent 1