Correspondence on Migraine

Impression:  
The clinical assessment suggests that the patient is suffering from chronic migraine with aura.
Past Medical History:  
1. Hypertension  
2. Asthma  
3. Depression  
Current Medications:  
1. Lisinopril 10 mg daily  
2. Salbutamol inhaler as needed  
3. Sertraline 50 mg daily  
Management Plan:  
1. Start amitriptyline 10 mg at night, increasing weekly up to 50 mg at night  
2. Prescribe sumatriptan 50 mg once daily for acute migraine episodes  
3. Recommend lifestyle changes including regular sleep patterns and adequate hydration  
Migraine advice to the patient and the GP:  
1. Self-education:  
   www.migrainetrust.org website (triggers and coping with migraine sections)  
2. Relaxation/Mindfulness:  
   a. Self-referral to psychology via IAPT NHS website  
   b. Headspace app  
   c. Online CBT  
3. Acute therapies:  
   a. Ibuprofen 800 mg or 900 mg of aspirin plus domperidone 20 mg or metoclopramide 10 mg—only considered ineffective if unsuccessful on less than 1/3 occasions.  
   b. Then switch to triptan taken with an anti-emetic, domperidone or metoclopramide, trying each triptan in the following order:  
      i. sumatriptan 50 mg once daily or 20 mg nasal spray,  
      ii. almotriptan 12.5 mg once daily,  
      iii. rizatriptan 10 mg tablets or as wafers once daily,  
      iv. zolmitriptan 2.5 mg increasing to 5 mg for subsequent attacks if 2.5 mg is insufficient,  
      v. eletriptan 40 mg once daily.  
   c. If ineffective, use naproxen 500 mg plus the most effective triptan plus anti-emetic.  
4. Migraine prophylaxis:  
   To reduce the frequency and impact of migraines, I suggest starting one of the prophylactic medications. The options are:  
   · Amitriptyline, starting at 10 mg at night, increasing weekly up to 50 mg at night, maximum 75 mg at night  
   · Propranolol, 10 mg twice daily, increasing weekly up to 40 mg twice daily, maximum 320 mg/day  
   · Candesartan 4 mg daily increasing up to 8 mg twice daily  
   For any prophylaxis, it should be continued for 6 weeks at the maximum dose (or maximum tolerated dose) before reviewing the headache diary and assessing efficacy.  
Thank you for referring this 35-year-old right-handed female who attended the neurology clinic. I am writing to summarize key findings from the recent consultation. She is a teacher who presents with recurrent, severe headaches characterized by a throbbing pain on one side of the head, often accompanied by nausea, vomiting, and sensitivity to light and sound. The headaches typically last between 4 to 72 hours and are preceded by visual auras.
The typical headache attack begins with visual disturbances such as flashing lights, followed by a severe throbbing headache on the right side of the head. The patient reports sensitivity to light and noise, nausea, and occasional vomiting. Identified triggers include stress, lack of sleep, and certain foods such as chocolate and cheese.
The impact of the headache on the patient is significant, affecting her ability to work and perform daily activities. She reports missing several days of work each month due to the severity of the attacks.
Previous treatments have included over-the-counter analgesics and sumatriptan, with limited success. She has not yet tried prophylactic medications.
There is a family history of migraine, with her mother and sister also experiencing similar symptoms.
The patient lives with her partner and two children. She does not smoke, drinks alcohol occasionally, and does not use recreational drugs. She holds a valid driving license and drives regularly.
The neurological examination:  
The neurological examination was unremarkable, with no focal neurological deficits observed.
Summary and recommendation:  
Based on the history and examination findings, the potential diagnosis is chronic migraine with aura. It is recommended to initiate prophylactic treatment with amitriptyline and continue acute treatment with sumatriptan. Lifestyle modifications and patient education on migraine management are also advised.