Question

Patient with asthma and mild depression presenting with hemicranial headache attacks (about once a month) is started on migraine prophylaxis. Which agent is preferred?

• A. Propranolol
• B. Carbamazepine
• C. Topiramate
• D. Duloxetine

Hint:

Beta blockers like propranolol are contraindicated in asthma, so pick the antiepileptic that prevents migraine.

Answer 1

The Correct Option is C

Step 1: Understanding the question:
A patient with asthma and mild depression has hemicranial (one sided) headache attacks about once a month. This sounds like migraine. A prophylactic drug has been planned. We have to pick the best agent for this particular patient.
Two patient factors guide the choice: asthma and depression.

Step 2: Recall the drugs used for migraine prophylaxis:
Prophylaxis is usually advised when attacks are frequent or disabling, or when acute drugs fail. The question tells us a prophylactic drug is being started, so we choose by the patient profile.
First line prophylactic drugs are propranolol (and other beta blockers), amitriptyline, topiramate, valproate, and flunarizine. Venlafaxine and candesartan are also used.

Step 3: Use the asthma:
Propranolol is a non-selective beta blocker. It blocks beta-2 receptors in bronchial smooth muscle and can cause severe bronchospasm. It is contraindicated in asthma.
Propranolol can also worsen depression and fatigue in some patients. So it is a poor choice for this patient.

Step 4: Check option (A) Propranolol:
It is an effective migraine prophylactic, but asthma is a contraindication. So (A) is wrong.

Step 5: Check option (B) Carbamazepine:
Carbamazepine is used in trigeminal neuralgia, epilepsy and bipolar disorder. It is not an established drug for migraine prophylaxis. Valproate is the antiepileptic that is used for it. So (B) is wrong.

Step 6: Check option (C) Topiramate:
Topiramate is an antiepileptic with good evidence for migraine prevention. It does not affect the airways. It has also been used in bipolar disorder, alcohol dependence and obesity. It suits this patient best among the options. So (C) is the answer.

Step 7: Check option (D) Duloxetine:
Duloxetine is an SNRI used in depression, diabetic neuropathy and fibromyalgia. It has no established role in migraine prophylaxis. Venlafaxine, not duloxetine, has some evidence. So (D) is wrong.

Final Answer:
The beta blocker propranolol is unsafe in asthma, carbamazepine and duloxetine have no standard role in migraine prevention, and topiramate is an effective prophylactic drug. The answer is option (C).