Clinical Challenge: What Do These Changes in Headache Pattern Signify?

A 32-year-old woman with a history of headaches since high school was seen by a headache specialist and initially diagnosed with episodic migraine with aura. Her typical headaches are unilateral over the temple as a throbbing, with sensitivity to light and sound. Headaches are occasionally preceded by a visual aura. Previously, the patient experienced approximately 1 migraine per week, treated with sumatriptan. When her auras first began, she underwent magnetic resonance imaging (MRI) of the brain, which was normal.

The patient was stable for many years, but following a minor car accident in which she experienced whiplash, a headache developed that would not go away. The patient noted that this headache was similar in character to, but milder than, her usual migraines. The headache is not present in the morning, but begins as she starts to get ready for work and worsens throughout the day. The patient reports that sumatriptan helps these symptoms “a bit,” but she has been using it daily for the last 2 weeks.

The woman consults her physician, and the results of the physician’s examination are normal. The patient denies recent fevers or travel. The patient tried a few of days of steroid medications, with few results, and asked about starting a preventive regimen for her migraines.

What would be the next step in the management of this patient’s headache?