Daily triptans for headache.

CLINICAL HISTORY This 47-year-old woman has a history of migraine since aged 4 years. Until 1 year ago, the headaches occurred one to two times per week, lasted all day, resulted in functional incapacity, and were not relieved by over-the-counter medications or nonsteroidal antiinflammatory drugs. About 10 years ago, she was taking Fiorinal #3 but stopped when she developed rebound headaches. She has been on multiple preventative medications including amitriptyline, -blockers, paroxetine, fluoxetine, and verapamil which were either not effective or stopped due to side effects. One year ago, she saw another neurologist and had an MRI scan of the brain with normal findings. She was started on oral sumatriptan, 50 mg, which completely relieved the headaches. However, the headaches increased in frequency and now occur every day. The headaches are the same as prior to a year ago. She reports a right or left temporal and retro-orbital sharp pressure associated with nausea, and light and noise sensitivity but no aura. The headaches are relieved within an hour after taking oral sumatriptan, which she is taking on a daily basis. Past medical history is negative. Neurologic examination was normal. I advised the patient that the increased frequency of the headaches could be rebound due to sumatriptan and that the headaches might decrease by restricting the sumatriptan to no more than 2 days per week and starting another preventative such as sodium valproate. She is concerned about the possible side effects of sodium valproate, which she has read can make you fat and bald. She also stated that the headaches were quite tolerable with the daily sumatriptan and she could not see the difference between taking daily sumatriptan as compared to a preventative which may or may not work and may have significant side effects. Questions.— Is there evidence to support daily triptan use for migraine? What would you recommend in this case?