Question of the week
Treating chronic migraines in young women can be especially difficult. Symptoms often shift over time, medications can cause side effects like brain fog, and treatment plans must account for lifestyle and long-term goals.
In this case, a 28-year-old woman faces a growing challenge: 15–20 migraines a month, each lasting hours and compounded by side effects from her current medication. Her practitioner is searching for a more effective and tolerable treatment.
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Patient Profile:
• 28-year-old woman
• Diagnosis: Suffers from frequent migraines
Current Status:
• Patient currently takes Topiramate 50mg twice a day, but notes that the medication gives her brain fog.
• Patient has been experiencing more frequent migraines—migraines have increased to a frequency of 15-20 migraines a month, lasting for about 2 hours each.
Patient’s Treatment Goals:
• Looking to begin a new treatment to lessen the number of migraines she experiences, as well as to decrease the severity of her migraines.
Questions for consult
Consults
Key takeaways about managing chronic migraines in young women:
- CGRP inhibitors are promising, but must be tailored
Preventive CGRP therapies like erenumab, fremanezumab, and galcanezumab are effective, but choice should depend on insurance coverage, side effects, and patient lifestyle—especially for young women of childbearing age. - Watch for medication overuse and cognitive side effects
Daily use of abortive drugs like sumatriptan may lead to medication-overuse headaches. The patient’s brain fog from Topiramate also highlights the need to balance treatment efficacy with cognitive impact. - Broader evaluation and alternatives should be considered
With rising migraine frequency, imaging is recommended. Other preventive options—like beta blockers, SNRIs, and tricyclics—should be explored before settling on a CGRP therapy.
Family Practice
"I would first be certain other preventative options had been tried, such as beta blockers, SNRIs, divalproex, or tricyclics. I would not necessarily have only one CRGP choice for all patients. My choice would be based on the preventative CGRP with the best insurance coverage for a specific patient, since these meds are prohibitively expensive for most patients.
Fortunately, I have had access to a pharmacist who can do some of the research into the best choice for each individual patient."
Neurology
"Aimovig is a good start, as is Emgality. My personal experience with Ajovy has been lackluster. By the way, as an aside, sumatriptan daily is probably not a good idea... Apart from its vasoconstriction properties, the patient may get a 'transformed headache' or 'medication-overuse headache'. Please ensure she is not taking any abortive drugs daily."
Unspecified/Other
"I would recommend fremanezumab (Ajovy) due to the patient being of childbearing potential- no known teratogenic risks. The quarterly self-injection option promotes adherence for a young, likely active patient."
Neurology
"Firstly, with the dramatic increase in frequency, an imaging study is a good idea. In terms of CGRP, Qulipta would be next given its efficacy and quick onset of action (as early as the first few days)."
Family Practice
"I would recommend starting a CGRP monoclonal antibody such as erenumab, fremanezumab, or galcanezumab as preventive therapy. These agents are effective in reducing monthly migraine days, have a favorable side-effect profile compared to oral preventives, and are particularly suitable for patients who have failed or cannot tolerate standard options. Erenumab is often chosen first due to its monthly self-injection and proven efficacy, though fremanezumab (quarterly or monthly dosing) and galcanezumab (monthly) are also strong options."
If you have experience treating chronic migraines in young women, visit the full case on Healthcasts to share what you have tried.
