What is the treatment for non-retractable migraine and sinus pressure?

From the Guidelines

For non-retractable migraine with sinus pressure, I strongly recommend starting with a combination of an NSAID, such as ibuprofen or naproxen, and a triptan, like sumatriptan, as first-line treatment, as suggested by the American College of Physicians guideline 1. This approach is based on the principle of individualized decision making, considering patient preferences and factors like route of administration and cost.

• Key points to consider:
  • NSAIDs like ibuprofen (400-600mg every 6 hours) or naproxen (500mg twice daily) can help with pain and inflammation.
  • Triptans, such as sumatriptan (50-100mg at onset, repeatable once after 2 hours if needed), are effective for migraine-specific treatment.
  • For moderate to severe acute episodic migraine headache, consider using CGRP antagonists-gepants (rimegepant, ubrogepant, or zavegepant) or ergot alkaloid (dihydroergotamine) if patients do not tolerate or have an inadequate response to combination therapy of a triptan and an NSAID or acetaminophen 1.
• Non-medication approaches are also crucial:
  • Apply warm compresses to sinuses for 10 minutes several times daily.
  • Use a saline nasal spray regularly.
  • Stay well-hydrated.
  • Practice stress reduction techniques like deep breathing or meditation. It's essential to counsel patients to begin treatment of migraine headache as soon as possible after its onset, using combination therapy to improve efficacy, and to be aware of medication overuse headache as a potential complication of migraine treatment 1.

From the Research

Treatment Options for Non-Retractable Migraine and Sinus Pressure

• The combination of sumatriptan and naproxen has been shown to be effective in the treatment of acute migraine attacks, with a greater effect than either medication alone 2.
• Paracetamol (acetaminophen) alone or in combination with an antiemetic is also an effective treatment for acute migraine headaches, with efficacy equivalent to oral sumatriptan 100 mg 3.
• Triptans, such as sumatriptan, are first-line treatments for moderate to severe migraines, while acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) are first-line treatments for mild to moderate migraines 4.
• The American Headache Society recommends the use of triptans, acetaminophen, and NSAIDs, such as aspirin, diclofenac, ibuprofen, and naproxen, as effective treatments for acute migraine attacks 5.
• A combination of aspirin, paracetamol, and caffeine has been shown to be superior to placebo in the treatment of acute migraine attacks, with a significant reduction in pain at 2 hours 6.

Treatment Strategies

• Taking medication early in an attack and using a stratified treatment approach can help ensure that migraine treatment is cost-effective 4.
• The administration of acute medications should follow the concept of "stratified care", with oral NSAIDs as the first choice for mild to moderate migraine attacks, and oral or nasal spray triptans and ergotamine/caffeine compounds recommended for moderate to severe attacks 5.
• Antiemetics can be used as a supplement to alleviate nausea and vomiting, and a combination of a triptan and a NSAID has been shown to yield a better efficacy compared to either therapy alone 5.

Safety and Efficacy

• Adverse events were more common with the combination of sumatriptan and naproxen than with placebo, but were mostly mild or moderate in severity 2.
• Paracetamol alone or in combination with an antiemetic had adverse event rates similar to placebo, while sumatriptan had more "major" adverse events 3.
• The use of acute treatment should be limited to a maximum of ten days a month to prevent medication-overuse headache 5.