Download Headache treatment:

Headache treatment:
Dr behnaz ansari
• Which kind of headache do you
diagnosis?
• How often was headache happened
in one month?
• Which kind of drugs do you use for
treatment?
• How many times do you continue
this treatment?
• Headache treatment depends upon the
frequency, severity, and symptoms of your
headache.
• Acute treatment refers to medicines you can
take when you have a headache to relieve the
pain immediately.
• Preventive treatment refers to medicines you
can take on a regular (usually daily) basis to
prevent headaches in the future.
Tension headache:
Tension-type headache in adults:
• Tension-type headache (TTH) is the most
common headache in the population. Yearly
prevalence rates for episodic TTH are
approximately 80 percent in men and women.
Due to its high prevalence in the population, TTH
causes a high degree of disability. Despite its
frequency, few placebo-controlled preventive
therapeutic trials have been conducted in TTH.
More research in the nonpharmacologic and
pharmacologic treatment of TTH is urgently
needed.
Acute treatment:
• A pain reliever may be recommended first for the treatment
of tension type headache. These drugs include:
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Aspirin
Acetaminophen (eg, Tylenol®)
Nonsteroidal antiinflammatory drugs (NSAIDs) such as ibuprofen (eg, Motrin or
Advil), indomethacin, or naproxen (eg, Naprosyn or Aleve).
Pain relievers should not be used too often because overuse can lead to
medication-overuse headaches or chronic daily headaches. If you respond to a
pain reliever, you should continue taking these with each headache. However:
Do not use pain relievers more than nine days per month on average, or more
than two doses per episode.
If a pain reliever does not control your headache, talk to your healthcare provider
for other suggestions.
People with gastritis (inflammation of the stomach), ulcers, kidney disease, and
bleeding conditions should not take products containing aspirin or NSAIDs.
• Pain medicine combinations — Mild pain
relievers are also available in combination with
caffeine, which enhances the drug's effect. As an
example, Excedrin® contains a combination of
acetaminophen-aspirin-caffeine. This
combination may be recommended if a pain
reliever alone does not relieve the headache.
However, this combination is not recommended
more than nine days per month due to the
potential risk of developing medication-overuse
headaches.
Preventive treatment:
Prophylactic headache treatment is indicated if the headaches
are frequent, long lasting, or account for a significant amount
of total disability . With respect to TTH, both the frequent
episodic subtype (1 to 14 headache days a month) and chronic
subtype (≥15 headache days a month) warrant prevention as
they may be associated with significant disability, especially
when accompanied by migraine, comorbid depression, or
anxiety .
Therefore, preventive treatment is appropriate for most
patients with chronic TTH, and is probably appropriate for
many patients with frequent episodic TTH. In contrast,
patients with infrequent episodic TTH (headache <1 day per
month) do not require preventive treatment.
• To achieve benefit, prophylactic headache therapy
requires a sustained commitment on the part of the
patient and clinician .
• It is important to address patient expectations and
consider patient preferences when deciding between
different preventive therapies. In addition, the patient
should be informed of the rationale for a particular
treatment, the expected benefits of therapy, the
duration of treatment that will likely be needed to
achieve improvement, and the possible and likely side
effects.
• PHARMACOLOGIC THERAPIES — A variety of
pharmacologic therapies have been studied for the
prophylactic treatment of TTH, as discussed in the
sections that follow. Evidence of efficacy is limited and
inconsistent , but perhaps is strongest for the tricyclic
antidepressants such as amitriptyline. Other
medications that may be useful include the
antidepressants mirtazapine and venlafaxine, the
anticonvulsants topiramate and gabapentin, and the
muscle relaxant tizanidine. In contrast, the available
evidence suggests that the selective serotonin uptake
inhibitors are not effective for TTH prophylaxis.
• Tricyclic antidepressants are reuptake inhibitors
of serotonin and noradrenaline.Amitriptyline also
reduces pericranial muscle tenderness, leading to
peripheral antinociception and inhibition of
central sensitization .
• Patients should be informed that amitriptyline is
an antidepressant agent but has an independent
action on pain . The beneficial effect for TTH is
not related to the presence of depression.
• We suggest the use of amitriptyline for patients with
frequent episodic TTH or chronic TTH. Exceptions
include patients with obesity, bipolar disease, or
cardiac conduction defects. This recommendation is
best suited for patients who have a preference for
pharmacologic treatment rather than behavioral or
other nonpharmacologic therapies. Our
recommendation is in agreement with 2010 guidelines
from the European Federation of Neurological
Societies for the treatment of TTH, which conclude
that amitriptyline has a clinically relevant prophylactic
effect in patients with chronic TTH and should be the
drug of first choice.
●Start the drug at the lowest dose, and increase the dose gradually
until therapeutic benefit is achieved, the maximum dose of the drug
is reached, or side effects become intolerable.
●Give the prophylactic medication an adequate trial in terms of
duration and dosage. Benefit is often first noted only after four to six
weeks of therapy . In addition, benefit may continue to accrue for
three months.
●Avoid overuse of analgesic medications. Ongoing analgesic overuse
must be eliminated, or preventive therapy will likely be ineffective.
●Once effective, maintain drug therapy for at least three to six
months. Thereafter, a slow taper off the medication can be
performed
• With these principles in mind, we start
amitriptyline at 10 to 12.5 mg nightly and
increase the dose in 10 to 12.5 mg steps every
two to three weeks as tolerated and as
needed for sleep, until there is improvement
in headache or until a maximum dose of 100
to 125 mg nightly is reached.
• Tricyclic medications are associated with an increased risk
of cardiac conduction abnormalities and arrhythmias.
Before initiating treatment with any of the cyclic
antidepressants, patients should be screened for cardiac
conduction system disease, which precludes the use of
these medications.
• We and others suggest that patients age 40 years and older
have a baseline ECG for this purpose. Patients younger than
age 40 can be screened by history for evidence of cardiac
disease. They do not require an ECG if the history is
negative. Patients who have a normal ECG before starting a
tricyclic antidepressant do not need additional ECG
monitoring while on the antidepressant, unless symptoms
arise suggestive of cardiac toxicity.
• Other antidepressants — Limited data from small
randomized controlled trials suggest that mirtazapine (a
noradrenergic and specific serotonergic antidepressant)
and venlafaxine (a serotonin-norepinephrine reuptake
inhibitor) may be effective for the treatment of chronic TTH
in patients without depression.
• Anticonvulsants — Limited evidence suggests that
topiramate and gabapentin may be beneficial for patients
with chronic TTH.
• Tizanidine — There is limited and conflicting data regarding
the effectiveness of tizanidine, a muscle relaxant and
antispasticity agent, for the prophylaxis of TTH
Trigger point injections — Trigger point injections require
more research, but limited data from small randomized
controlled trials suggest that lidocaine injections may
reduce headache frequency and, thereby, total acute
medication use for patients with frequent episodic or
chronic TTH .
Botulinum toxin injections — In a 2012 meta-analysis,
eight placebo-controlled trials evaluated botulinumtoxinA
(botulinum toxin type A) for patients with chronic TTH .
Botulinum toxin injections led to a small reduction in the
number of headaches per month, but the result was not
statistically significant.
Trigger point injection:
• BEHAVIORAL THERAPIES —European guidelines for the
treatment of TTH published in 2010 state that non-drug
management should be considered for all patients with TTH
even though the scientific evidence is sparse and
contradictory.
●Regulation of sleep, exercise and meals
●Cognitive-behavioral therapy
●Relaxation
●Biofeedback
Acupuncture — The available evidence regarding acupuncture
for TTH suggests that any benefit is likely to be modest.
Migraine headache:
Migraine treatment:
• Abortive Therapy
• Numerous abortive medications are used for
migraine. The choice for an individual patient
depends on the severity of the attacks,
associated symptoms such as nausea and
vomiting, comorbid problems, and the
patient's treatment response.
Moderate
Severe
Extremely Severe
NSAIDs
Naratriptan
DHE (IV)
Isometheptene
Rizatriptan
Opioids
Ergotamine
Sumatriptan (SC,NS)
Dopamine antagonists
Naratriptan
Zolmitriptan
Rizatriptan
Almotriptan
Sumatriptan
Frovatriptan
Zolmitriptan
Eletriptan
Almotriptan
DHE (NS/IM)
Frovatriptan
Ergotamine
Eletriptan
Dopamine antagonists
Dopamine antagonists
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The 2 categories of migraine-specific oral medications are triptans and ergot
alkaloids. The specific ergot alkaloids include ergotamine and dihydroergotamine
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(DHE).The specific triptans include the following] :
Sumatriptan
Rizatriptan
Zolmitriptan
Naratriptan
Almotriptan
Eletriptan
Frovatriptan
All the triptans are most effective when taken early during a migraine and all may be
repeated in 2 hours as needed, with a maximum of 2 doses daily.
Triptans should not be used more than 3 days weekly, to avoid transformed migraine and
medication overuse headache.
• However, triptans should not be taken by patients with known or
suspected coronary artery disease, as they may increase risk of
myocardial ischemia, infarction, or other cardiac or cerebrovascular
events. Do not administer vasoconstrictors, such as ergots or
triptans, to patients with known complicated migraine; treat their
acute attacks with one of the other available agents, such as NSAIDs
or prochlorperazine.
• The dose of rizatriptan must be reduced to 5 mg in patients taking
propranolol. Sumatriptan, zolmitriptan, and rizatriptan are primarily
metabolized by monoamine oxidase (MAO) and should be avoided
in patients taking MAO-A inhibitors.
• The first combination product of a triptan and an NSAID, Treximet,
was approved by the FDA in 2008. Treximet contains sumatriptan
and naproxen sodium.
ANTIEMETICS
• Intravenous (IV) metoclopramide and IV or
intramuscular (IM) chlorpromazine, prochlorperazine,
and droperidol can be used as monotherapy for acute
migraine headache. These medications act as
antiemetics mainly because they are dopamine
receptor antagonists. In addition, they are effective for
reducing migraine headache pain.
• Of note, most of these drugs (ie, chlorpromazine,
prochlorperazine, droperidol, and diphenhydramine)
are associated with a risk of QT interval prolongation
and torsades de pointes.
• For initial treatment of patients who present to the hospital
emergency department with moderate to severe migraine,
particularly if the migraine is accompanied by vomiting or
significant nausea, we suggest initial treatment with either
subcutaneous sumatriptan 6 mg or a parenteral antiemetic
agent rather than other migraine-specific drugs (Grade 2C);
reasonable antiemetic choices are intravenous (IV)
metoclopramide (10 mg) or prochlorperazine (10 mg).
• IV dihydroergotamine (DHE 45) 1 mg combined with IV
metoclopramide 10 mg is also a reasonable alternative for
treatment of intractable severe migraine in the emergency
department, and it can be used if metoclopramide
monotherapy is ineffective
Comorbid Condition
Medication
Hypertension
Beta blockers
Angina
Beta blockers
Stress
Beta blockers
Depression
Tricyclic antidepressants, SSRIs
Overweight
Topiramate, protriptyline
Underweight
Tricyclic antidepressants (nortriptyline, protriptyline)
Epilepsy
Valproic acid, topiramate
Mania
Valproic acid
• we recommend adjunctive treatment with a
single dose of parenteral dexamethasone (10 to
25 mg) to reduce the risk of early headache
recurrence for patients who are treated with
standard abortive therapy for migraine headache
in the emergency department or clinic. However,
frequent use of adjunctive dexamethasone for
headache increases the risk of glucocorticoid
toxicity and should be avoided.
• Opioids and barbiturates should not be used for
the treatment of migraine
Complementary and Alternative
Treatments:
• A guideline from the American Academy of Neurology and the American
Headache Society (AAN/AHS) recommends offering butterbur to patients
with migraine to reduce the frequency and severity of migraine attacks
(level A recommendation).Patients on butterbur require monitoring of
liver enzymes.
• The AAN/AHS found moderate evidence of effectiveness for riboflavin
(vitamin B2), magnesium, and feverfew. A 3-month, randomized,
controlled trial of high-dose riboflavin (400 mg) found that riboflavin was
superior to placebo in reducing attack frequency and headache days.
• A randomized, controlled trial of coenzyme Q10 (CoQ10) documented that
CoQ10 is effective and well tolerated for migraine prophylaxis.Results of a
trial in children and adolescents suggested that prophylaxis with CoQ10
may lead to earlier improvement in headache severity than does placebobased prophylaxis, but the trial found no long-term difference in headache
outcomes between the CoQ10 and placebo groups.[117]
• Melatonin has also been used for migraine prevention.
• Body work - Eg, chiropractic, massage, and
craniosacral therapy
• Nutritional/herbal supplements - Eg, vitamins
and herbs
• Yoga
• Acupressure and acupuncture
• Biofeedback
Status Migrainosus Treatment :
• an intractable migraine attack (status
migrainosus), that is, an attack lasting longer
than 72 hours, should be addressed in an
urgent care or emergency department. In rare
cases, patients may need to be hospitalized
for a short period and may need to be treated
with intravenous valproate or
dihydroergotamine(intravenously/subcutaneo
usly/intramuscularly) for a few days.
Treatment of Menstrual Migraine:
• Abortive therapy for menstrual migraine is the same as for
nonmenstrual migraine. Patients with frequent and severe
attacks may benefit from short-term, perimenstrual use of
preventive agents (eg, frovatriptan).
• Patients with menstrual and nonmenstrual migraine who
are receiving continuous preventive therapy and
experiencing breakthrough menstrual migraine headaches
may benefit from perimenstrual elevation of the dose of
the preventive medication.
• Patients who do not respond to standard preventive
measures may benefit from hormonal therapy.
Perimenstrual estrogen supplementation with estradiol (0.5
mg orally twice a day, or a 1-mg transdermal patch) may be
beneficial.
Cluster headache:
Cluster headache::
ACUTE TREATMENT — Subcutaneous sumatriptan
and oxygen inhalation are first-line treatments for
acute cluster headache attack . Other agents with
some evidence of effectiveness include ergots,
lidocaine, and octreotide.
Oxygen — Although controlled trial evidence is
limited , oxygen therapy is considered to be safe
and effective for aborting cluster headache.
Octreotide appears to be effective and well
tolerated in the treatment of acute cluster
headaches.
PREVENTIVE TREATMENT :
— Preventive therapy should be started as soon as possible at the
onset of a cluster episode. Verapamil is the drug of choice for
prophylaxis of episodic and chronic cluster headache Other agents that
may be effective include glucocorticoids(, We suggest using prednisone
60 to 100 mg once a day for at least five days, and then tapering by
decreasing the dose 10 mg every day. Intravenous and oral
administration of glucocorticoids can be successfully combined),
lithium(The initial dose of lithium should be 20 mg/kg, usually 300 mg
two or three times daily, with dose increases every four to five days
based upon lithium levels; the typical maintenance dose is 900 to 1200
mg/day given in three to four divided doses of the regular formulation,
or in two divided doses of the sustained release formulation. The
lithium plasma level should be monitored and kept between 0.6 and
1.2 mmol/L ), topiramate, and methysergide.
Pizotifen – The antiserotonergic drug pizotifen (3 mg
daily) was effective in cluster headache prophylaxis in a
single-blind, placebo-controlled trial .
●Valproic acid – Evidence regarding the utility of valproic
acid in cluster headache prophylaxis is limited and
conflicting. Valproic acid can be used in a dose between 5
and 20 mg/kg daily.
●Capsaicin – Repeated ipsilateral intranasal application of
capsaicin was reported to be effective in approximately
two-thirds of patients with cluster .headache in two
open-label studies
Ergotamine – Some experts advocate the combination drug caffeine (250 mg)
and ergotamine (2 mg) given as a rectal suppository to prevent cluster
headache attacks during the night
●Melatonin – Oral melatonin (10 mg) was more effective than placebo in
double-blind, randomized controlled study involving 20 patients, but the
response rate was relatively low (5 of 10 patients)
●Indomethacin – Although short-term indomethacin treatment is considered
ineffective for cluster headache, there are reports of occasional patients
meeting diagnostic criteria for cluster headache who have responded to
indomethacin when used for several weeks at higher doses (≥225 mg daily) .
●Triptans – A multicenter placebo-controlled trial of 169 patients found that
oral sumatriptan was not effective in preventing cluster headache attacks .
However, limited data from small uncontrolled studies and case reports
suggest that treatment with two longer-acting triptans – oral naratriptan and
frovatriptan is beneficial for cluster headache prevention.
For patients with episodic cluster headache
prophylactic medications should be tapered after
the expected duration of the cluster has passed.
The drugs can be restarted at the lowest effective
dose if symptoms recur.
For patients with chronic cluster headache who
have a good response to preventive
pharmacotherapy, we suggest a dose reduction trial
of preventive medications every other month.
Medication overuse headache:
Treatment :
• Medication overuse headache (MOH) is a
common problem in clinical practice that
needs to be properly managed in order to
increase the likelihood of successful chronic
daily headache treatment.
• Withdrawal of the overused medication as soon as
possible is the treatment of choice for medication
overuse headache (MOH) . It is also important to
educate patients about the detrimental effects of
analgesic overuse.
• Bridge (transitional) therapy may be useful during drug
withdrawal to provide symptomatic relief. For most
patients, a preventive (prophylactic) medication aimed
at the suspected background primary headache
disorder (eg, migraine) should be initiated either
during or immediately following withdrawal
PATIENT EDUCATION:
• Clinicians must educate patients about the
detrimental effects of analgesic overuse .
Patients need to understand that analgesics
have the potential to cause MOH, and that
analgesic overuse can negate the effectiveness
of headache preventive measures
WITHDRAWAL OF THE OVERUSED
MEDICATION :
— Withdrawal of overused acute medications can be accomplished on
an outpatient or inpatient basis . Most patients can be managed as
outpatients. Outpatient withdrawal is particularly appropriate for
patients who are highly motivated and do not take barbiturates or
tranquilizers .
Significant complications may occur as a consequence of drug
dependency when withdrawing from opioids, benzodiazepines and
barbiturates, and the choice between outpatient and inpatient
withdrawal of these agents remains an area of debate . Some experts
favor inpatient withdrawal with close observation and medical
monitoring in the first several days . However, it is often reasonable to
try outpatient treatment first unless serious withdrawal problems
develop or are considered likely.
With overuse of barbiturates, opioids, or benzodiazepines, the pace of
withdrawal depends on the amount and frequency of usage. Abrupt
outpatient withdrawal is routinely done in clinical practice if intake of the
offending agent is not very high. However, we suggest a gradual taper when
these agents (particularly barbiturates or benzodiazepines) are being used
frequently or at high doses.
The taper can usually be accomplished in two to four weeks.
For patients withdrawing from butalbital, we recommend phenobarbital
taper for seizure prophylaxis, particularly when butalbital is stopped abruptly
or when high doses are being used. Our suggested regimen is phenobarbital
30 mg twice daily for two weeks, followed by 15 mg twice daily for two
weeks.
When there is concern for opioid withdrawal symptoms, treatment with a
once-weekly transdermal clonidine patch (0.1 to 0.2 mg/24 ; alternatively,
clonidine can be given as needed for withdrawal symptoms (0.1 to 0.2 mg
three times daily, titrated up or down based on symptoms).hours) for one to
two weeks may help.
Withdrawal symptoms — During the period of analgesic withdrawal,
the headaches are likely to exacerbate before subsequently improving
. In addition to increased headache, withdrawal symptoms can include
nausea, vomiting, restlessness, anxiety, nervousness, and disturbed
sleep . Withdrawal symptoms typically last 2 to 10 days , but
occasionally can persist for as long as two to four weeks .
The duration and severity of withdrawal headache depends on the
type of overused analgesic. In one prospective study of 95 patients,
the mean duration of withdrawal headache was 4.1 days for triptans,
6.7 days for ergots, and 9.5 days for analgesics (most of which were
combined with codeine, caffeine, or barbiturates) . Overall, withdrawal
from triptan-induced MOH was less severe than withdrawal from other
analgesics.
Bridge therapy :
• Bridge therapy, also known as transitional
therapy, is used to provide symptomatic relief
for patients with MOH during withdrawal of
the offending medication. Bridge therapy
strategies that appear to have some merit
include the short-term use of certain oral
(naproxen, tizanidine, glucocorticoids) and
intravenous (dihydroergotamine,
prochlorperazine, lidocaine, valproic acid,
aspirin) medications.
we suggest use of bridge therapy during outpatient
withdrawal of the offending medication using either
long-acting NSAIDs(naproxen 550 mg twice daily for two
to four weeks while the overused acute medication is
withdrawn . An alternative is naproxen 550 mg twice
daily for one week, and then naproxen once daily for
one week), prednisone, or subcutaneous DHE.
Antiemetics are also frequently needed in clinical
practice.
For inpatient withdrawal, we suggest intravenous bridge
therapy using dihydroergotamine plus metoclopramide,
prochlorperazine, valproate sodium, or methylprednisolone
Case Presentation: Part I
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A 25-year-old female with no significant past medical history is referred to the
neurology clinic by her primary care office for headaches.
The patient notes that approximately 6-months ago she started to develop
throbbing bifrontal headaches that were associated with nausea and photophobia.
When she has these headaches, she must sit in a dark room and try to sleep. After
she wakes up, she usually feels better, but on some occasions the headaches
persist. For these headaches, she used over-the-counter ibuprofen, which initially
helped. At the start, the headaches occurred only once every few weeks and
responded to ibuprofen. However, the headaches have progressed to the point
where she has them every day. She has been taking the ibuprofen every day and
multiple times a day with no relief. More recently, she has had to miss work for
these headaches.
There is no associated visual blurring, premonitory aura, diplopia, slurred speech,
numbness, or weakness. The headaches do not awaken her from sleep. She does
not drink caffeine. She denies any chance that she could be pregnant.
• Her past medical history includes an appendectomy in
childhood. Otherwise, she denies any chronic illness. There
is no history of kidney stones or asthma.
• Her only medication is the daily ibuprofen, which she takes
multiple times a day. She is not on any oral contraceptives.
• She has no known drug allergies.
• She does not smoke, drink alcohol, or use illicit substances.
She is an elementary school teacher.
• She has a strong family history of migraine headaches on
her maternal side. There is no history of any other
neurologic diseases.
• On physical examination, she is a well-developed and
well-nourished female in mild distress. She appears
bothered by the light in the examination room. She is
afebrile. Her blood pressure is 110/70, pulse is 75, and
respiratory rate is 12.
• She has no tenderness to palpation over her shoulders,
neck, or occiput. No bruits are heard over her neck.
There are no murmurs or abnormal heart sounds.
• Neurological examination and her imaging were
normal.
Treatment??
• You discuss with the patient that her original headaches were consistent
with migraine headaches. However, more recently you suspect her
headaches have evolved into daily medication-overuse headaches from
excessive abortive analgesia use. You counsel her that her normal
neurologic examination and unremarkable imaging are reassuring that
there is not a more sinister underlying etiology to these complaints.
• As she is having headaches daily, you feel she would benefit from a
preventive migraine medication. After reviewing the AAN guideline
“Update: Pharmacologic Treatment of Episodic Migraine Prevention in
Adults,”1 you select propranolol, as it has a Level A recommendation. You
start the patient on propranolol 80 mg extended release once daily and
discuss potential side effects, including dizziness. You have asked her to
limit her ibuprofen use. You also discuss nonpharmacologic strategies for
migraine prevention, such as good sleep, exercise, and regular meals.
Finally, you ask the patient to keep a headache diary to assess therapeutic
response and identify common triggers.
Case Presentation: Part II
• The patient returns to the neurology clinic in 3 months.
She feels the propranolol helped her headaches, as her
headache frequency decreased to twice a week.
Furthermore, these migraine headaches responded
well to ibuprofen. Unfortunately, she has had problems
with dizziness since starting the propranolol. The
dizziness has not passed despite the fact she has been
on the medication for a few months. She denies any
new neurologic symptoms. She has not had to miss any
work in the last 3 months. After keeping a diary, she
suspects that pepperoni might trigger some of her
headaches.
• You discuss with her that, although you are happy she has
improved, it is important to strive for better control of her
headaches. As she is having side effects from the
propranolol, you do not feel this medication should be
increased. You decide to taper her off the propranolol over
the course of a week. She will then start topiramate, which
also has a Level A recommendation in the AAN guideline.
The topiramate will be started at 25 mg daily and titrated
over 4 weeks to 50 mg twice a day. You discuss potential
side effects, including kidney stones, cognitive changes,
and paresthesias. She is encouraged to continue the
ibuprofen, which aborts her headaches nicely. She will
continue her headache diary.
Case Presentation: Part III
• The patient returns to the neurology clinic in
another 3 months. She is doing very well and
has had no headaches in over 1 month. In
fact, she has not required any ibuprofen in
over a month. She is tolerating the topiramate
without difficulty .
• You discuss that you are happy that she has such
good headache control on topiramate. She is
encouraged to continue the medication as
written and is given refills. You review the
previously discussed nonpharmacologic strategies
for migraine prevention. Finally, you advise the
patient to make you aware if she is currently
pregnant or is planning on becoming pregnant,
as this medicine has a Category D pregnancy risk
factor. She is scheduled for a routine follow-up in
the future.