MKSAP Quiz: 2-year history of migraine
A 20-year-old man is evaluated for a 2-year history of migraine that began when he started college. Migraine episodes occur 6 to 12 days per month, with more frequent episodes associated with increased stress from difficult assignments or final examinations. All physical examination findings, including vital signs, are unremarkable. What is the most appropriate preventive measure?
A 20-year-old man is evaluated for a 2-year history of migraine that began when he started college. Migraine episodes occur 6 to 12 days per month, with more frequent episodes associated with increased stress from difficult assignments or final examinations.
The migraine pain is typically bifrontal and steady, becoming severe when he bends forward. When the pain is severe, he also experiences sensitivities to light and noise but has no visual aura, nausea, or vomiting; neck pain and a slight vertiginous sensation may accompany the most intense episodes. Ibuprofen, naproxen, or diclofenac provides only limited pain relief. He has had no other medical problems or symptoms.
All physical examination findings, including vital signs, are unremarkable.
Which of the following is the most appropriate preventive measure?
A. Citalopram
B. Gabapentin
C. Indomethacin
D. Lamotrigine
E. Venlafaxine
MKSAP Answer and Critique
The correct answer is E. Venlafaxine. This content is available to MKSAP 19 subscribers as Question 79 in the Neurology section. More information about MKSAP is available online.
The most appropriate preventive measure is venlafaxine (Option E). The patient has migraine without aura. Migraine is a chronic neurobiologic disorder characterized by attacks of head pain and various associated features. Attacks are often separated by periods of normal brain function. Even at times of symptom freedom, patients possess an underlying predisposition for migraine episodes possibly because of a biologically based inherent hypersensitivity of the central nervous system. Exposure to certain internal and external factors may trigger a migraine attack in migraine-prone individuals while leaving those without such a predisposition unaffected. Patient surveys indicate stress or a poststress period (let-down effect) as the most common triggering factor. Changes in female hormones, sleep or meal pattern disruptions, weather factors, and strong sensory light, sound, or odor stimuli are also frequently reported as triggers. The goal of migraine prevention is the reduction of migraine frequency, intensity, and duration. The best agents may reduce migraine frequency by half in approximately half of the patients treated. Pharmacologic prophylaxis should be considered when the headache frequency reaches 5 days per month and almost always is initiated when the frequency exceeds 10 days per month. Venlafaxine, a serotonin-norepinephrine reuptake inhibitor, is among the agents with Level A or Level B evidence of effectiveness in episodic migraine prevention. Propranolol, timolol, metoprolol, amitriptyline, topiramate, sodium valproate, erenumab, fremanezumab, eptinezumab, and galcanezumab are also considered beneficial in this setting.
No evidence supports the use of selective serotonin reuptake inhibitor antidepressants, such as citalopram (Option A), in migraine prevention.
Although commonly prescribed for migraine prevention, gabapentin (Option B) has not been shown to be useful in migraine prophylaxis.
Although indomethacin (Option C) may be useful in the management of hemicrania continua, paroxysmal hemicrania, and (usually) primary stabbing and primary cough headache, none of these conditions is present in this patient.
Lamotrigine (Option D) has shown some benefit in reducing the likelihood of cortical spreading depression, felt to be a surrogate for migraine aura, in animal models of migraine. Clinical studies have shown no benefit in patients with migraine.
Key Point
- Venlafaxine, propranolol, timolol, metoprolol, amitriptyline, topiramate, sodium valproate, erenumab, fremanezumab, eptinezumab and galcanezumab are all beneficial in episodic migraine prevention.