A 28-year-old woman is reviewed in the neurology clinic. She suffers from up to two migraines per month, and is currently only treated with sumatriptan at the time of an acute episode. Most recently she has been diagnosed with a patent foramen ovale after an echocardiogram. She is asymptomatic from this and continues to play professional hockey. Only other past medical history of note is asthma for which she takes a low dose salmeterol fluticasone combination inhaler. Physical examination in the clinic is entirely unremarkable, her body mass index is mildly elevated.
Which of the following is the most useful prophylactic intervention against further migraines?
Atenolol 25mg once a day
Indomethacin 100mg once a day
Closure of patent foramen ovale
Topiramate 50mg twice a day
Sodium valproate 100mg twice a day
Topiramate is the most appropriate intervention here, with asthma contraindicating use of beta blockade. It is an effect agent for prophylaxis in migraine, and may promote modest weight loss.
Beta-blockers are the standard intervention with respect to migraine prophylaxis. According to the British Association for the Study of Headache (BASH), although atenolol isn’t licensed for this indication, an initial low dose of 25mg is indicated. Other guidelines endorse the use of propranolol. In this case however beta blockers are best avoided given the history of asthma.
The key point of note here is that in both the PRIMA and PREMIUM studies which looked at closure of a patent foramen ovale (PFO) as treatment for migraine, no benefit with respect to symptoms was seen. For this reason in patients who are otherwise asymptomatic, PFO closure may not be necessary. Indomethacin is used as a treatment for paroxysmal hemicrania, sodium valproate is a second or third line option for migraine prophylaxis.