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Migraine prevention — ABIM Board MCQ

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HardNeurologyMigraine preventionABIM Board

A 36-year-old has migraine without aura on 10 days monthly and uses sumatriptan on nine days. She has hypertension, plans pregnancy within a year and wants prevention. Which initial preventive strategy is preferred?

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Correct answer: C — Begin propranolol with pregnancy planning and blood-pressure monitoring

The best answer is “Begin propranolol with pregnancy planning and blood-pressure monitoring”. Her attack frequency warrants prevention. Propranolol is effective and can also treat hypertension, with pregnancy planning discussed prospectively. Topiramate and valproate carry important fetal risks, while CGRP monoclonal antibodies have limited pregnancy data and long persistence. Continued frequent acute use risks medication-overuse headache.

Reference: AAN/AHS Guideline: Migraine Prevention in Adults: https://pubmed.ncbi.nlm.nih.gov/22529202/