Untitled design-6Sumatriptan was only mildly effective; what would you consider next Dr. Robbins?

I do not want to quit the triptan class, because these are the most likely medications to stop the migraine, with minimal side effects. I would substitute rizatriptan, 1 tab every 3 hours prn, 3 per day at most. The naproxen, limited to 1 or 2 tabs per day, has been useful for her daily headaches, and ondansetron helps her nausea. She has only used 3 tabs of hydrocodone as an “escape” analgesic.

Heather is currently on topiramate, 50 mg qhs; quetiapine, slowly increasing to 50 mg qhs; and OTC naproxen, rizatriptan, and ondansetron pen, with occasional hydrocodone as a back-up. In addition, Heather is watching triggers (regular meals, sleeping on time, etc.), exercising 20 minutes per day, and seeing a psychotherapist for therapy and biofeedback.

She reports that the quetiapine seemed to help her mood the following day, but is sedating and she cannot take more than 25 mg at night. Rizatriptan has not been helpful and she had to resort to the hydrocodone for her last migraine.

Since Heather seemed to tolerate the low dose of quetiapine fairly well, and it may be starting to help her moods, we would continue this drug. On a mood stabilizer, such as lithium, lamotrigine, or quetiapine, Heather may be able to tolerate a low-dose antidepressant.

As far as her abortive medicines, the sumatriptan and rizatriptan have not been particularly effective. At this point, it is worthwhile to try one more triptan, either sumatriptan injections, the most effective form, or zolmitriptan (Zomig) nasal spray. Since she does not want to give herself an injection, we would prescribe the Zomig nasal spray. As usual, the instructions will be to use this early in the headache. This is a very effective triptan that partly bypasses the gastrointestinal tract and has a relatively quick onset of action.

Practical Pain Management

June, 2015

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