What is the best management approach for a 35-year-old female with a history of migraines, newly diagnosed hypertension, and catamenial migraines, who is currently experiencing breakthrough headaches despite treatment with naproxen (nonsteroidal anti-inflammatory drug) 275mg three times a day (TID) for 3 days and flunarizine (calcium channel blocker) 5mg once daily at bedtime (ODHS), with pending magnetic resonance imaging (MRI), magnetic resonance angiography (MRA), and magnetic resonance venography (MRV) results?

Management of Catamenial Migraine with Breakthrough Headaches and Newly Diagnosed Hypertension

Immediately escalate to IV metoclopramide 10 mg plus IV ketorolac 30 mg for breakthrough headaches, then transition to short-term perimenstrual prophylaxis with naproxen 500 mg twice daily starting 2-3 days before expected menstruation and continuing through day 3 of menses, while initiating daily preventive therapy with propranolol 80-240 mg/day to address both migraine frequency and hypertension. 1

Immediate Management of Breakthrough Headaches

Your current regimen of naproxen 275 mg TID is suboptimal—this dose is too low and the evidence for 275 mg is insufficient. 1, 2

For acute breakthrough attacks:

• IV combination therapy is first-line: Metoclopramide 10 mg IV plus ketorolac 30 mg IV provides rapid relief through synergistic mechanisms—metoclopramide offers direct analgesic effects via central dopamine receptor antagonism (not just antiemetic effects), while ketorolac provides 6 hours of analgesia with minimal rebound risk. 1
• If oral therapy is preferred, escalate to naproxen 500 mg (not 275 mg) at headache onset, which can be repeated every 12 hours, with maximum 1250 mg on day 1, then 1000 mg/day thereafter. 1, 2
• Critical frequency limitation: Restrict all acute medications to no more than 2 days per week to prevent medication-overuse headache, which paradoxically increases headache frequency. 1, 3

Short-Term Perimenstrual Prophylaxis (Mini-Prophylaxis)

For catamenial migraines specifically, implement short-term prophylaxis:

• Naproxen 500 mg twice daily starting 2-3 days before expected menstruation and continuing through day 3 of menses (total 5-7 days per cycle). 4, 5
• Alternative: Frovatriptan 2.5 mg twice daily during the perimenstrual window has the strongest evidence among triptans for short-term prevention (four randomized controlled trials), but triptans are relatively contraindicated in your patient with newly diagnosed hypertension until blood pressure is well-controlled. 4, 6
• Rizatriptan has the best overall evidence for acute treatment of menstrual migraine (pain-free response 33-73% at 2 hours), but again, defer until hypertension is controlled. 4

Daily Preventive Therapy: The Ideal Choice for Dual Benefit

Propranolol 80-240 mg/day is the optimal preventive medication for this patient because it simultaneously addresses both migraine prevention and hypertension control—a dual therapeutic benefit. 1, 3, 6

Why propranolol is superior in this case:

• First-line preventive medication with consistent evidence for migraine efficacy 3
• Treats newly diagnosed hypertension 6
• No contraindications in this 35-year-old female (assuming no asthma, heart failure, or peripheral vascular disease)
• Start at 80 mg/day and titrate up to 240 mg/day based on response and blood pressure control 3

Alternative preventive options if propranolol is contraindicated:

• Avoid flunarizine escalation in hypertensive patients—calcium channel antagonists can cause hypotension and are contraindicated with concurrent beta-blocker use. 7
• Topiramate is second-line but has more adverse effects (cognitive impairment, paresthesias, weight loss) 3
• Amitriptyline 30-150 mg/day is appropriate if comorbid depression or tension-type headaches exist 1

Critical Considerations for Hypertension

Good blood pressure control may directly reduce migraine frequency and severity. 6

• Establish baseline blood pressure and ensure it's well-controlled before considering triptans, as triptans are relatively contraindicated in uncontrolled hypertension due to vasoconstrictive effects. 1, 6
• Many migraine medications can exacerbate hypertension (triptans, ergots), while some antihypertensives worsen headaches, so careful medication selection is essential. 6
• Propranolol addresses both conditions simultaneously, making it the most rational choice. 3, 6

Flunarizine Reassessment

Flunarizine 5 mg ODHS should be discontinued or not escalated in this patient with newly diagnosed hypertension because:

• Calcium channel antagonists are contraindicated in patients with hypotension and should be used cautiously with concurrent beta-blockers 7
• Flunarizine is contraindicated in depression and Parkinson's disease 7
• Propranolol is superior for this patient's dual pathology 3, 6

Await MRI/MRA/MRV Results Before Finalizing Long-Term Plan

While the above recommendations are appropriate for typical migraine management, ensure no secondary causes are identified on neuroimaging before committing to long-term preventive therapy. New-onset hypertension in a 35-year-old with worsening migraines warrants exclusion of secondary headache disorders (venous sinus thrombosis, arterial dissection, mass lesions). 1

Algorithm Summary

1. Acute breakthrough headaches: IV metoclopramide 10 mg + IV ketorolac 30 mg, or oral naproxen 500 mg (not 275 mg) 1, 2
2. Limit acute medication use: Maximum 2 days per week to prevent medication-overuse headache 1, 3
3. Short-term perimenstrual prophylaxis: Naproxen 500 mg BID starting 2-3 days before menses through day 3 of cycle 4, 5
4. Daily preventive therapy: Propranolol 80-240 mg/day (addresses both migraine and hypertension) 3, 6
5. Discontinue or avoid escalating flunarizine in the setting of hypertension 7
6. Defer triptans until hypertension is well-controlled, then consider rizatriptan for acute menstrual migraine attacks 4, 6
7. Await neuroimaging results before finalizing long-term management 1

Common Pitfalls to Avoid

• Do not continue naproxen 275 mg TID—this dose is inadequate and lacks evidence. 1, 2
• Do not allow frequent acute medication use—this creates medication-overuse headache and worsens the cycle. 1, 3
• Do not use triptans in uncontrolled hypertension—wait until blood pressure is optimized. 1, 6
• Do not combine or escalate flunarizine with propranolol—calcium channel antagonists are contraindicated with beta-blockers. 7
• Do not ignore the dual benefit of propranolol—it's the ideal choice for migraine prevention plus hypertension control. 3, 6