MRCP2-3462

MRCP2-3462

A 33 year-old teacher presents to the neurology clinic.

For the past year, she has been experiencing severe headaches. These headaches usually occur in the morning and sometimes wake her up from sleep. The pain is sudden and stabbing, located behind her right eye. During the attacks, she feels the need to pace around the room and pound her head to ease the pain. Her right eye becomes watery and her nose congested. She has also noticed that her left pupil appears enlarged during the attacks. The pain is so severe that she has considered jumping out of the top floor of the school building where she works. Each attack lasts for one to two hours, and she feels fine between the attacks.

She has been keeping a detailed headache diary, which shows that she had a period of nine days in January with several attacks daily, followed by a headache-free period in February and March. In April, she developed severe headaches that occurred almost every day until June. She then had another period of relief until August, and so on.

The patient has no other past medical history and no allergies.

Upon examination, there are no remarkable findings.

What is the best prophylactic treatment for this patient’s headaches?