Case Study: 34-Year-Old Female with Ongoing Migraine Headaches

SCENARIO 2

AB is a 34-year-old female presenting to the clinic with ongoing migraine headaches. “I’m still getting migraines once a week, even though I take Ubrelvy when they start.” She reports experiencing 3 to 4 migraine attacks per month, typically associated with throbbing pain on one side, light sensitivity, and nausea. Migraines can last from 6-24 hours. AB has been taking Ubrelvy 50 mg po as needed at migraine onset for the past 3 months. She says it helps sometimes, but not consistently, and the pain often returns in a few hours. PMH: migraine without aura (diagnosed at age 27) Current medications: Ubrelvy 50 mg po PRN at onset of migraine, ondansetron 4 mg ODT dissolve on tongue PRN nausea, may repeat in 8 hours if needed. Vitals: BP 118/74, HR 78. What treatment plan would you implement for AB? What medication changes would you make? How would you monitor the effectiveness of this plan, and what patient education would you provide? Is a patient with migraines more likely to start on an acute or preventive agent? What are examples of each? AB is a 34-year-old female presenting to the clinic with ongoing migraine headaches.

Scenario 2

AB is a 34-year-old female with a history of migraine without aura who presents with ongoing headaches despite the use of Ubrelvy (ubrogepant) as needed. She experiences three to four migraines per month, lasting up to 24 hours, and reports that her current acute treatment provides only partial and inconsistent relief. Given her migraine frequency and functional impairment, she is a candidate for preventive therapy in addition to optimizing acute treatment.

Treatment Plan and Medication Changes

Continue Ubrelvy 50 mg po PRN at migraine onset, but consider increasing to 100 mg po once at onset (maximum 200 mg/24 hours), as higher doses have shown greater efficacy for some patients (Dighriri et al., 2023).

Add a preventive agent:

Propranolol 40 mg po BID, #60 tablets, 2 refills

Classification: Non-selective beta-blocker.

MOA: Decreases neuronal excitability and modulates vascular tone, reducing migraine frequency and severity (Shahrokhi & Gupta, 2023).

Provide an alternative acute option if Ubrelvy remains insufficient:

Sumatriptan 50 mg po at migraine onset; may repeat once in 2 hours, maximum 200 mg/24 hours, #9 tablets, 1 refill.

AB is a 34-year-old female presenting to the clinic with ongoing migraine headaches

Monitoring Effectiveness

Ask patient to keep a headache diary documenting frequency, severity, duration, and response to medications.

Reassess in 8–12 weeks to evaluate preventive therapy effectiveness.

Monitor for propranolol side effects (e.g., bradycardia, hypotension, fatigue) (Shahrokhi & Gupta, 2023).

Track any medication overuse (risk of rebound headaches if acute agents are used for more than 10 days/month).

Patient Education

Explain that preventive medications take several weeks to show benefit.

Stress adherence to propranolol even if headaches are not daily.

Educate on avoiding migraine triggers (e.g., disrupted sleep, caffeine, alcohol, stress, certain foods).

Encourage lifestyle modifications such as hydration, stress management, and exercise.

Reinforce safe use of acute medications (do not exceed maximum doses).

Acute vs. Preventive Therapy

Most patients begin with acute therapy (e.g., triptans, NSAIDs, gepants like ubrogepant) for infrequent migraines. Patients with frequent or disabling migraines benefit from preventive therapy (e.g., propranolol, topiramate, amitriptyline, CGRP monoclonal antibodies) (Pellesi et al., 2024). In AB’s case, because of frequent attacks and incomplete control with acute treatment, adding preventive therapy is appropriate AB is a 34-year-old female presenting to the clinic with ongoing migraine headaches