A patient returns to the clinic for migraine follow up. They were started on Topiramate (Topamax) 6 weeks ago, however headache days have not decreased, partly because the patient has not been taking medication consistently due to busy work and life schedule. What is an appropriate 2nd line agent to start on this patient given their lifestyle?

A. Verapamil (Calcium Channel Blocker): Verapamil is primarily used for cluster headaches rather than migraine prophylaxis. It requires daily dosing and careful titration, which may be challenging for a patient with an inconsistent medication schedule. B. Botox (Neuromuscular blocker): OnabotulinumtoxinA is indicated for chronic migraine, typically in adults with 15 or more headache days per month. It involves repeated injections every 12 weeks in a clinical setting, which may not be practical for patients seeking flexible, lifestyle-compatible options. C. Ajovy (CGRP inhibitor): CGRP monoclonal antibodies, such as Ajovy, are administered subcutaneously monthly or quarterly. This infrequent dosing improves adherence for patients with busy schedules and provides effective migraine prophylaxis when oral daily medications are not consistently taken. D. Dexamethasone (Corticosteroid): Corticosteroids are not standard preventive therapy for migraine and are used mainly for acute status migrainosus in short courses. Chronic use is discouraged due to significant systemic side effects, making it inappropriate as a second-line preventive option.