What is an appropriate migraine prophylaxis regimen for a 54‑year‑old pre‑diabetic woman with monthly migraine attacks, photophobia, inadequate relief from rizatriptan (Rizamelt) and ibuprofen/acetaminophen, and who cannot use triptans daily?

Migraine Prophylaxis for a 54-Year-Old Pre-Diabetic Woman with Frequent Monthly Attacks

Start propranolol 80 mg daily (titrate to 240 mg/day as tolerated) as first-line preventive therapy, strictly limit rizatriptan to ≤2 days per week, and add naproxen 500 mg at migraine onset to enhance triptan efficacy. 1, 2, 3

Immediate Action: Address Medication Overuse Risk

• Your patient is at high risk for medication-overuse headache because she is experiencing migraines 4–5 days per month and likely using rizatriptan more than twice weekly. 1
• Rizatriptan must be restricted to ≤2 days per week (maximum 10 days per month) to prevent paradoxical worsening of headache frequency. 1, 2
• Exceeding this limit creates a self-perpetuating cycle where the medication itself sustains chronic migraine. 1

Why Preventive Therapy Is Mandatory Now

• Preventive therapy is indicated because she has ≥2 migraine attacks per month producing disability lasting ≥3 days, and she requires acute medication more than twice weekly. 1, 3
• The goal is to reduce attack frequency by ≥50% and restore responsiveness to acute treatments. 2
• Waiting longer will only allow medication-overuse headache to develop. 1

First-Line Preventive Medication: Propranolol

• Propranolol 80–240 mg/day is the strongest first-line preventive agent with FDA approval and robust randomized trial evidence. 1, 3
• Start at 80 mg daily and titrate upward every 2–3 weeks based on tolerability and response. 1
• Allow 2–3 months to reach maximal efficacy before declaring failure. 2
• Propranolol is weight-neutral compared to other beta-blockers and does not worsen pre-diabetes. 1

Alternative First-Line Options If Propranolol Is Contraindicated

• Timolol 20–30 mg/day has equally strong evidence if propranolol causes intolerable side effects. 1
• Avoid topiramate despite its weight-loss benefit, because it carries risks of depression, cognitive slowing, and reduced contraceptive efficacy. 4
• Avoid valproate/divalproex entirely if there is any possibility of pregnancy due to teratogenic risk. 1

Optimize Acute Treatment Strategy While Starting Preventive Therapy

• Continue rizatriptan 10 mg but take it early when pain is still mild, not after headache becomes severe. 2, 3
• Add naproxen 500 mg simultaneously with rizatriptan to prevent the 40% relapse rate within 48 hours. 2, 3
• This combination (triptan + NSAID) is superior to either agent alone and represents the strongest acute treatment recommendation. 1
• Strictly enforce the 2-days-per-week limit for all acute medications combined (rizatriptan, ibuprofen, paracetamol). 1, 2

If Rizatriptan Continues to Fail After Optimization

• Try a different triptan first (eletriptan 40 mg, zolmitriptan 2.5–5 mg, or naratriptan 2.5 mg), as failure of one triptan does not predict failure of others. 2, 5
• Each triptan should be trialed for 2–3 migraine episodes before abandoning it. 2
• Subcutaneous sumatriptan 6 mg provides the highest efficacy (59% complete pain relief at 2 hours) if oral triptans fail. 1, 3

Critical Lifestyle Modifications to Enhance Preventive Efficacy

• Ensure adequate hydration (she currently drinks <1 liter daily, which is insufficient). 4
• Dehydration is a common migraine trigger and undermines preventive therapy effectiveness. 4
• Implement regular meal timing, limit caffeine intake, establish sleep hygiene, and introduce stress-management techniques (yoga, mindfulness). 4
• These behavioral interventions reduce reliance on acute medications and improve preventive therapy outcomes. 4

Timeline and Expected Outcomes

• Weeks 1–4: Propranolol titration phase; continue optimized acute treatment (rizatriptan + naproxen ≤2 days/week).
• Months 1–3: Assess preventive efficacy; goal is ≥50% reduction in monthly migraine days. 2
• If inadequate response at 3 months: Increase propranolol to maximum tolerated dose (up to 240 mg/day) or switch to alternative first-line preventive (timolol, amitriptyline 30–150 mg/day if comorbid depression/insomnia). 1, 3

Critical Pitfalls to Avoid

• Do not allow her to increase acute medication frequency in response to ongoing attacks while waiting for preventive therapy to work—this guarantees medication-overuse headache. 1
• Do not prescribe opioids or butalbital compounds as rescue medications; they have questionable efficacy, cause dependency, and worsen rebound headaches. 1, 3
• Do not delay preventive therapy while trialing multiple acute strategies—this patient already meets criteria for prevention. 1, 2

When to Refer to Neurology

• If propranolol and one alternative first-line preventive both fail after adequate 3-month trials at therapeutic doses. 2
• If medication-overuse headache develops despite counseling (acute medication use ≥10 days/month). 1
• If migraines progress to chronic pattern (≥15 headache days per month), requiring consideration of onabotulinumtoxinA or CGRP monoclonal antibodies. 1, 6