Neurology Question 79

A 30-year-old woman is evaluated for difficult-to-treat migraine. She has had severe headaches, usually on the first day of menses, since menarche. The pain is hemicranial, pulsatile, and associated with severe nausea and vomiting but no aura. She frequently awakens with the attack already in progress. Ibuprofen was helpful in controlling migraine pain during her teenage years and early 20s but was replaced 5 years ago by oral eletriptan after the pain was no longer controlled; this drug now also is ineffective in relieving symptoms. A trial of oral frovatriptan for menstrual migraine relief also has been unsuccessful. The patient reports receiving intravenous dihydroergotamine and magnesium at an urgent care facility twice in the past 3 months as treatment of refractory headaches. On physical examination, blood pressure is 98/60 mm Hg and pulse rate is 72/min. All other physical examination findings, including those from a neurologic examination, are normal.

Which of the following is the most appropriate next step in treatment?

A Butalbital

B Hydrocodone

C Naproxen

D Orally dissolvable rizatriptan

E Subcutaneous sumatriptan

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