Pearls of Wisdom: Migraine Medications

Question: For a patient with a migraine, if propranolol prophylaxis has failed, what is your next step?
 
Case: Erika is a 28-year-old with a recurrent migraine. Although triptans effectively abort her headaches, she would like to use a preventive tool. Propranolol 160 mg/d was only minimally ineffective for her. Her sister had experienced success with nadolol.
 
Based upon her clinical history, you should:
 
A. Consider nadolol, because it is likely to be more effective.
B. Switch to a different class (eg, milnacipran).
C. Beta-blocker/shmeta-blocker: They’re all the same, so if one didn’t work, forget it.
D. Switch to a beta blocker with ISA (eg, pindolol).

What would you recommend?
(Answer and discussion on next page)

Louis Kuritzky, MD, has been involved in medical education since the 1970s. Drawing upon years of clinical experience, he has crafted each year for almost 3 decades a collection of items that are often underappreciated by clinicians, yet important for patients. His “Pearls of Wisdom” as we like to call them, have been shared with primary care physicians annually in an educational presentation entitled 5TIWIKLY (“5 Things I Wish I Knew Last Year”…. or the grammatically correct, “5 Things I Wish I’d Known Last Year”).

Now, for the first time, Dr Kuritzky is sharing with the Consultant360 audience. Sign up today to receive new advice each week.