50 year old female RN who works the night shift with recurrent headaches that are worsening in frequency and duration. The patient shares they progress to migraines and she has light sensitivity and nausea. Unremarkable neuro exam. MSK exam reveals decreased neck flexor/extension strength. Medical conditions include thyroid cancer and now hypothyroidism, uncontrolled GERD, pacemaker, osteoarthritis, obesity, and anxiety. History includes kidney stones. She currently takes omeprazole 20 mg BID, duloxetine 90 mg daily, gabapentin 400 mg twice daily and 800 mg at bedtime, and sumatriptan 100 mg as needed at the onset of migraine. Originally she was getting relief from the sumatriptan but she no longer is. We have also trialed magnesium glycinate 600 mg nightly, fish oil, turmeric, riboflavin 400 mg daily, and ubiquinol 200 mg daily but without a noticeable difference. She does mention she has been seen in the past by neurology for trigeminal nerve block and had great relief with no headaches for several years. I would like to start her on preventive medication. I am hesitant to prescribe Topamax given her history of kidney stones. I don’t believe propranolol would be a good choice given her history of pacemaker. I also don’t want to prescribe Effexor since she is already on an SSRI. She is also seeing PT and counseling.
Would you recommend starting amitriptyline or nortriptyline as a next choice? What next steps do you recommend for this patient?