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Case 1: AM is suffering from migraines that may have recently evolved into medication-overuse headaches (excessive ibuprofen use). AM may benefit from a prophylactic migraine therapy.
Although numerous medications are touted for migraine prophylaxis, only 6 medications are rated as having strong evidence of established efficacy (level A) by the American Academy of Neurology’s migraine prevention guidelines. These medications include antiepileptics (divalproex sodium, valproic acid, topiramate) or 1 of 3 beta-blockers (metoprolol, propranolol, timolol). The relative efficacy of these agents has not been well established; therefore, choosing between agents should be based on the presence of comorbid conditions, side effect profiles, and tolerability. Successful therapy is often defined by a 50% reduction in headache frequency, and trial and error with a couple of different medications is often needed. AM will likely still need to take medications to treat acute symptoms if she suffers a migraine attack.
Because AM has no medical history or comorbid conditions, 1 of the beta-blockers (ie, propranolol 80 mg extended release once daily) is a reasonable first choice. Antiepileptics may not be the optimal choice for AM because she is of child-bearing age and antiepileptics have been linked to birth defects.
In addition to prophylactic medication, avoiding migraine triggers can also help decrease migraine frequency. Triggers include foods such as cheese, alcohol, chocolate, aspartame (eg, in diet sodas), and nitrate-containing foods (eg, processed meats); stress; changes in sleep patterns; and environmental factors (eg, noise, odors, hunger, thirst). Patients should be advised to keep a headache diary to assess their response to therapy and identify these common triggers.
Case 2: According to the new JNC 8 guidelines, treating high BP to a goal of <150/90 mm Hg reduces patients’ risk of coronary disease, stroke, renal failure, and death. However, the guidelines also note there is evidence suggesting that lowering systolic BP further (<140 mm Hg) in this age group likely provides no additional benefit.
Because of previous guideline recommendations (JNC 7 called for a systolic BP of <140 mm Hg), many treated patients have BPs well below the new goal. However, according to JNC 8, in the general population 60 years and older, pharmacologic treatment does not need to be adjusted unless treatment is poorly tolerated or adversely affecting patient health or quality of life (ie, Expert Opinion—Grade E).
Consequently, no change to HC’s antihypertensive regimen is required.