Migraine Headache: The Daily PANCE Blueprint
A 61-year-old female with a history of tobacco abuse, hypertension, coronary artery disease status post percutaneous intervention, and previous cerebrovascular accident presents to your clinic complaining of chronic intense, throbbing unilateral headaches that occur every other week. She says she will see “bright lines and shapes” before the headache occurs. NSAIDs have not helped. She is asking you for other options. Which of the following medications would be contraindicated in the management of this patient?
A. Sumatriptan
B. Rimegepant (Nurtec)
C. Acetaminophen
D. Candesartan
E. None of the above
Answer and topic summary
The answer is A. Sumatriptan
The patient has a migraine, a specific type of headache. It’s been suggested that migraines occur due to “cortical spreading depression,” which is a wave of depolarization that occurs across the cerebral cortex by activation of the trigeminovascular system. There are also other factors that play a role (calcitonin gene-related peptide aka CGRP), serotonin, genetics, etc. Clinical features include pre-migraine prodrome, aura, a throbbing, usually unilateral headache, photophobia, phonophobia. Many times there is a precipitating factor (stress, odors, hormones, etc). Acute treatments include NSAIDs, triptans, acetaminophen, and CGRP antagonists (Nurtec, Ubrelvy). Preventive treatments include anti-hypertensives (BBs, verapamil, candesartan), anti-seizure meds (topiramate, valproate, gabapentin), CGRP antagonist injections (Aimovig, Ajovy, Emgality), and even botox injections. Know the contraindications to these medications, especially triptans!
Contraindications to triptans:
- Ischemic heart disease
- Prinzmetal angina
- Hx of myocardial infarction
- Hx of cerebrovascular events (stroke, TIA)
- Hx of hemiplegic or basilar migraine
- Peripheral vascular disease
- Uncontrolled hypertension
- Wolff-Parkinson-White syndrome or arrhythmias associated w/ accessory conduction pathway disorders
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Smarty PANCE Content Blueprint Review:
Covered under ⇒ PANCE Blueprint Neurology ⇒ ⇒
Also found on PAEA Family Medicine EOR, Internal Medicine EOR, and Emergency Medicine Rotation EOR topic list
