Medicolegal Aspects of Headache Medicine

A 54-year-old man with an active 1 pack per day smoking history, a history of coronary artery disease (status-post stenting), and chronic cluster previously refractory to a wide variety of therapeutic interventions (including gamma knife radiosurgery) presents complaining of cluster attacks that recently had worsened in their frequency and pain intensity. His prophylactic regimen included verapamil, lithium, topiramate, and methylergonovine. Each day over the previous 6 weeks, he had taken 1-3 tablets of sumatriptan 100 mg for incipient cluster attacks, and every night he had administered sumatriptan 6 mg subcutaneously for attacks that awakened him from sleep. Advised by his treating physician that he was overusing sumatriptan and that he must cut back on his use/frequency of the drug, he replied, “Doc, I’d rather die.” His wife confirmed that he had threatened suicide consequent to the recent exacerbation of cluster, and she had felt compelled to hide the key to his gun cabinet. The patient was instructed to increase his dose of verapamil, begin taking melatonin 12 mg qhs and to start a 2-week tapering course of prednisone.A serum testosterone level was low, and he was treated in clinic with intramuscular injections of testosterone gel.His prescriptions for sumatriptan 100 mg tablets no.27 and injectable sumatriptan 6 mg no. 27 were refilled; at the patient’s request, the treating physician previously had obtained from the insurance carrier involved authorization for monthly quantities of sumatriptan higher than those typically allotted. During the next 48 hours, the patient took 2 doses of sumatriptan 100 mg po and administered sumatriptan 6 mg subcutaneously on 3 occasions, the last 2 for a nocturnal cluster attack that atypically persisted following the initial injection. That attack was complicated by acute chest pain, and he was transported to the emergency department (ED) via EMT. At the ED, his blood pressure was 180/116, and electrocardiogram findings were consistent with acute anterior and inferior myocardial infarction.The patient survived and subsequently underwent coronary angiography and coronary artery bypass and grafting. The neurologist treating his cluster was sued for simultaneously prescribing methylergonovine and sumatriptan and for willfully prescribing excessive amounts of the latter; both drugs were purported to have precipitated the patient’s acute myocardial infarction.