What are the next steps in treatment for a 55-year-old female with a long history of migraines, previously controlled on Imitrex (sumatriptan) and Topamax (topiramate), now experiencing worsening symptoms with multiple headaches daily and no signs of stroke or neurological deficit?

Worsening Migraine Despite Current Therapy: Next Steps

This patient requires immediate initiation of preventive therapy while simultaneously optimizing acute treatment, as daily headaches indicate either medication-overuse headache (MOH) or inadequate disease control—both requiring preventive intervention rather than escalating acute medications. 1, 2

Critical First Step: Rule Out Medication-Overuse Headache

Assess current medication frequency immediately. 1, 2

• If using Imitrex (sumatriptan) or Topamax for acute treatment more than 2 days per week, MOH is the likely diagnosis 2, 3
• MOH presents as daily or near-daily headaches with marked increase in migraine frequency 3
• Common pitfall: Escalating acute medication use in response to worsening headaches creates a vicious cycle that perpetuates daily headaches 2

Workup Requirements

Screen for red flags requiring urgent neuroimaging: 1

• Progressive headache pattern (suggests space-occupying lesion)
• Thunderclap onset (subarachnoid hemorrhage)
• Headache aggravated by Valsalva maneuvers (intracranial hypertension)
• New headache in patient >50 years with weight loss or personality changes (secondary headache)
• Atypical aura features (TIA, stroke, arteriovenous malformation)

If no red flags are present and neurological examination is normal, neuroimaging is not required. 1

Immediate Management Algorithm

Step 1: Initiate Preventive Therapy NOW

Daily preventive medication is mandatory for this patient, as she has multiple headaches daily. 2, 4, 5

First-line preventive options (choose based on comorbidities): 4, 5

• Propranolol 80-240 mg/day (avoid if asthma, bradycardia, or depression) 2
• Continue or optimize Topamax (topiramate) 50-200 mg/day if currently used only for acute treatment—this should be daily preventive dosing 4
• Amitriptyline 30-150 mg/day if comorbid tension-type headache or insomnia 2, 4
• Divalproex sodium 500-1500 mg/day (avoid in women of childbearing potential due to teratogenicity) 4

Preventive therapy requires 2-3 months for oral agents to demonstrate efficacy. 2

Step 2: Address Medication-Overuse Pattern

If MOH is present (acute medication use >2 days/week): 2, 3

• Immediately limit all acute medications to maximum 2 days per week 2
• Warn patient that headaches may temporarily worsen during first 2-4 weeks of withdrawal 3
• Bridge with short course of corticosteroids (prednisone 60 mg daily for 5 days, then taper) if needed for severe rebound 1

Step 3: Optimize Acute Treatment Strategy

Switch acute treatment approach—do not simply increase current regimen frequency. 1, 2

If one triptan fails, try a different triptan: 1, 6

• Failure of sumatriptan does not predict failure of rizatriptan, eletriptan, or zolmitriptan 1
• Consider subcutaneous sumatriptan 6 mg if oral formulation inadequate (59% complete pain relief at 2 hours vs. lower rates with oral) 2

Combination therapy is superior to monotherapy: 2, 6

• Sumatriptan 50-100 mg PLUS naproxen sodium 500 mg taken together at headache onset provides 130 more patients per 1000 achieving sustained pain relief compared to either alone 2
• This combination should be used maximum 2 days per week 2

Alternative if triptans contraindicated or all fail after adequate trials (3 consecutive attacks each): 1

• Gepants (ubrogepant, rimegepant) or ditans (lasmiditan) as third-line agents 1, 2
• Intranasal DHE (dihydroergotamine) 1

Step 4: Adjunctive Acute Treatment

Add antiemetic even without nausea for synergistic analgesia: 1, 2, 6

• Metoclopramide 10 mg orally 20-30 minutes before triptan 2, 6
• Prochlorperazine 25 mg orally if metoclopramide not tolerated 1, 6

Critical Contraindications to Verify

Before continuing or escalating triptan therapy, confirm absence of: 3

• Uncontrolled hypertension (triptans contraindicated) 3
• Coronary artery disease, prior MI, or Prinzmetal's angina 3
• Peripheral vascular disease 3
• Hemiplegic or basilar migraine 3
• Stroke or TIA history 3

At age 55 with cardiovascular risk factors, consider cardiovascular evaluation before continuing triptans if multiple risk factors present (hypertension, diabetes, smoking, obesity, family history of CAD). 3

Follow-Up Timeline

• 2 weeks: Assess medication-overuse pattern compliance and withdrawal symptoms 2
• 4-6 weeks: Evaluate acute treatment response with new strategy 1
• 8-12 weeks: Assess preventive therapy efficacy (expect 50% reduction in headache frequency as success) 4, 5
• If no improvement by 3 months: Switch to alternative preventive medication class 4, 5

Key Pitfalls to Avoid

• Do not increase acute medication frequency in response to daily headaches—this worsens MOH 2, 3
• Do not delay preventive therapy—daily headaches are an absolute indication for prevention 2, 4
• Do not use opioids or butalbital-containing compounds—these cause dependency, rebound headaches, and loss of efficacy 1, 2
• Do not assume triptan failure means all triptans will fail—individual responses vary significantly 1