What is the most appropriate acute management for a patient with a debilitating headache, associated with nausea and vomiting, and normal laboratory and imaging results?

From the Guidelines

The most appropriate acute management for this patient's pain is sumatriptan (option D). This patient is presenting with classic symptoms of migraine: severe headache with nausea, vomiting, and photophobia (sensitivity to light, as evidenced by the request to turn off lights). According to the study by 1, there is good evidence for the use of triptans, such as sumatriptan, in the acute management of migraine attacks. Sumatriptan is a 5-HT1 receptor agonist that causes vasoconstriction of cranial blood vessels and is a first-line treatment for acute migraine attacks. It works quickly to relieve migraine pain and associated symptoms.

The patient's normal neurological examination and normal brain MRI rule out secondary causes of headache, supporting the diagnosis of primary headache disorder like migraine. The study by 1 also recommends selecting a nonoral route of administration for patients whose migraines present early with nausea or vomiting as a significant component of the symptom complex, and treating nausea and vomiting with an antiemetic. However, since the patient is able to tolerate oral medications, oral sumatriptan can be considered.

While propranolol and topiramate are used for migraine prevention, they are not appropriate for acute treatment, as stated in the study by 1, which recommends them as first-line agents for the prevention of migraine headache. Gabapentin is primarily used for neuropathic pain, and acetazolamide is used for conditions like idiopathic intracranial hypertension, which is not indicated by the patient's normal funduscopic examination and imaging.

Key points to consider in the management of this patient's pain include:

• The patient's symptoms are consistent with a migraine attack
• The use of triptans, such as sumatriptan, is supported by good evidence for the acute management of migraine attacks
• The patient's normal neurological examination and normal brain MRI rule out secondary causes of headache
• The patient's ability to tolerate oral medications makes oral sumatriptan a viable option.

From the FDA Drug Label

The efficacy of sumatriptan tablets in the acute treatment of migraine headaches was demonstrated in 3, randomized, double-blind, placebo-controlled trials. In all 3 trials, the percentage of patients achieving headache response 2 and 4 hours after treatment was significantly greater among patients receiving sumatriptan tablets at all doses compared with those who received placebo For patients with migraine-associated nausea, photophobia, and/or phonophobia at baseline, there was a lower incidence of these symptoms at 2 hours (Trial 1) and at 4 hours (Trials 1,2, and 3) following administration of sumatriptan tablets compared with placebo

The most appropriate acute management to address this patient's pain is Sumatriptan.

• The patient's symptoms, including debilitating headache, nausea, and vomiting, as well as photophobia, are consistent with a migraine headache.
• The patient's request to turn off the lights in the room suggests photophobia, a common symptom of migraine.
• Sumatriptan has been shown to be effective in the acute treatment of migraine headaches, with a significant reduction in headache severity and associated symptoms such as nausea, photophobia, and phonophobia 2.

From the Research

Patient Presentation

The patient presents with a 6-hour history of a debilitating headache associated with nausea and vomiting. The patient's medical history is remarkable for insomnia, and he takes zolpidem as needed.

Symptoms and Examination Findings

• Debilitating headache
• Nausea and vomiting
• Requests that the lights in the room be turned off, suggesting photophobia
• No abnormalities on physical examination, neurologic examination, or funduscopic examination
• Laboratory studies and MRI of the brain with contrast show no abnormalities

Appropriate Acute Management

Based on the patient's symptoms, the most appropriate acute management to address this patient's pain is:

• Sumatriptan, a selective serotonin (5-HT)1B/1D agonist, which is effective in relieving migraine headache and associated symptoms such as nausea, photophobia, and phonophobia 3, 4, 5, 6, 7
• The patient's symptoms, including debilitating headache, nausea, vomiting, and photophobia, are consistent with a migraine attack, making sumatriptan a suitable treatment option

Treatment Options

• Sumatriptan is available in various formulations, including subcutaneous, oral, intranasal, and rectal, allowing for flexible treatment options depending on the patient's needs and preferences 3, 4, 5, 6, 7
• The subcutaneous route of administration may be preferable for patients experiencing nausea and/or vomiting, as it can provide rapid relief from symptoms 7