I am 39 with HTN. Which migraine treatment is safe for me?

Question

Hi doctor,

I am a 39-year-old woman who has been taking migraine injections (Erenumab 70 mg monthly) for the last six months. Before starting treatment, I used to have 12 to 14 migraine attacks per month, but now they have reduced to about five to six per month. However, I also have hypertension, with blood pressure usually around 150/95 mmHg, even while taking Losartan.

My recent lipid profile showed LDL 142 mg/dL, HDL 36 mg/dL, and triglycerides 190 mg/dL. I also have hypothyroidism, with TSH at 6.4 µIU/mL, and

I am on Levothyroxine 75 mcg daily. My BMI is 30.8 kg/m², and I feel tired most of the time. Sometimes, after the injection, I notice constipation and mild injection site pain. I am also worried because my doctor said CGRP inhibitors like erenumab might raise blood pressure.

My fasting sugar is 116 mg/dL, suggesting prediabetes, and I did not want my medicines to worsen my risks.

I want to know whether I should continue these injections or consider other options like botulinum toxin, gepants, or neuromodulation devices for migraine prevention. Which treatment would be safest and most effective for me, given my hypertension, thyroid disease, and metabolic risks?

Please advise.

Answer 1

Hi,

Welcome to icliniq.com

Erenumab has clearly reduced the frequency of your migraines, but your concern is valid since calcitonin gene-related peptide (CGRP) inhibitors, including Erenumab, have been linked in some cases to increased blood pressure, which is particularly important in your situation.

Given your already uncontrolled hypertension and metabolic risks, constipation and injection site pain are also known side effects.

Alternatives such as

OnabotulinumtoxinA (Botox) injections are effective for patients with chronic migraine, are generally not associated with blood pressure elevation, and may be safer for someone with cardiovascular risk factors.
Oral CGRP antagonists known as gepants, like Atogepant or Rimegepant, are newer options for prevention and tend to have fewer cardiovascular concerns compared with monoclonal antibodies, though their long-term safety data are still being collected.
Non-drug approaches such as neuromodulation devices, including external vagus nerve stimulation or transcranial magnetic stimulation, can provide additional benefit and are free of systemic side effects, making them appealing for people with complex medical backgrounds.
At the same time, optimizing your blood pressure control, adjusting thyroid hormone replacement to normalize thyroid-stimulating hormone (TSH), and addressing cholesterol and weight through lifestyle changes and possibly medication will improve both migraine control and overall cardiovascular safety.

The decision to continue Erenumab or switch should be made with your neurologist and primary physician together, weighing how much benefit you are experiencing against the risk of worsening hypertension, but alternatives like Botox or gepants may offer a safer balance for you if blood pressure remains difficult to control.

I hope this answers your query.

Thank you.