What is the best course of treatment for a patient with a 5-6 year history of migraines, currently managed with Maxalt (rizatriptan) wafers, who is experiencing an increased frequency of migraines potentially triggered by hormonal changes and stress?

Management of Increasing Migraine Frequency in Patient on Rizatriptan

This patient requires immediate initiation of preventive therapy due to using acute medication at least twice monthly with increasing frequency, which places them at high risk for medication-overuse headache and indicates inadequate migraine control. 1, 2

Immediate Assessment Priorities

• Determine current headache frequency by asking: "Do you feel like you have a headache of some type on 15 or more days per month?" as patients often underreport milder headaches while only mentioning severe episodes 1
• Screen for medication-overuse headache (MOH) if rizatriptan is being used more than 2 days per week (≥10 days/month for triptans), as this creates a vicious cycle leading to daily headaches 2, 3
• Rule out red flags for secondary headache through history: sudden onset/thunderclap pattern, progressive worsening, fever with neck stiffness, or change from usual attack pattern 2, 3

Acute Treatment Optimization

For current and future attacks, switch from rizatriptan monotherapy to combination therapy:

• Prescribe rizatriptan 10 mg PLUS naproxen sodium 500 mg taken together at migraine onset while pain is still mild, as this combination is superior to either agent alone with 130 additional patients per 1000 achieving sustained relief at 48 hours 2, 3
• Add metoclopramide 10 mg oral taken 20-30 minutes before the rizatriptan/naproxen combination for synergistic analgesia beyond just treating nausea 2, 3
• Strictly limit all acute medications to NO MORE THAN 2 DAYS PER WEEK to prevent medication-overuse headache 2, 3

Preventive Therapy Initiation (Critical Priority)

Start preventive therapy immediately as this patient meets multiple criteria: using acute medication at least twice monthly, experiencing increased frequency, and likely has attacks producing disability 1, 2, 4, 5

First-Line Preventive Options:

Propranolol 80-160 mg daily (extended-release) is the preferred first-line option with consistent evidence of efficacy, particularly effective for stress-triggered migraines 1, 3, 4, 5

Alternative first-line options if propranolol contraindicated:

• Topiramate 50-100 mg daily (titrate slowly from 25 mg) - the only agent with proven efficacy in randomized controlled trials specifically for chronic migraine, though note it can affect oral contraceptive efficacy at doses >200 mg/day 1, 6
• Amitriptyline 30-75 mg nightly - particularly useful if patient has comorbid tension-type headaches or depression 1, 4, 5
• Candesartan 16-32 mg daily - effective alternative especially if beta-blocker contraindications exist 3

For Hormonally-Triggered Migraines:

If attacks cluster around menstruation (perimenstrual window):

• Consider short-term prophylaxis with frovatriptan 2.5 mg twice daily starting 2 days before expected menstruation and continuing for 6 days, which has the strongest evidence among triptans for menstrual migraine prevention 6
• Alternative: naproxen sodium 500 mg twice daily during the perimenstrual window (same timing as frovatriptan) 6

If perimenopausal with erratic cycles:

• Consider continuous combined hormone therapy (estrogen patch 50 mcg/day with progesterone if uterus present) to stabilize fluctuating estrogen levels that trigger migraine, as cyclic hormone therapy will worsen attacks 7

Critical Pitfalls to Avoid

• Do not allow continued escalation of acute medication frequency in response to increasing attacks - this creates MOH and worsens the problem; instead, transition immediately to preventive therapy 2, 3
• Do not prescribe opioids or butalbital-containing compounds as they lead to dependency, rebound headaches, and loss of efficacy 2
• Ensure adequate trial duration of preventive medication (2-3 months minimum) before declaring failure, as efficacy takes time to manifest 1, 4, 5
• Start preventive medications at low doses and titrate gradually to minimize side effects and improve compliance 4, 5

Stress Management Component

Address stress triggers through:

• Recommend behavioral interventions including biofeedback, relaxation training, and stress-coping therapies as adjuncts to pharmacotherapy 4
• Consider these particularly important given patient's identified stress as a trigger 4

Follow-Up Plan

• Reassess in 2-3 months to evaluate headache frequency (days per month), disability level, medication adherence, and adverse effects 3
• Maintain headache diary throughout to accurately track frequency and treatment response 1, 4
• If preventive therapy successful, continue for 6-12 months before attempting to taper to minimum effective dose 4