What treatment options are available for a 13-year history of left-sided migraines that have not responded to paracetamol (acetaminophen) and ibuprofen?

From the Guidelines

For a 13-year history of left-sided migraines unresponsive to paracetamol and ibuprofen, the most effective next step is to add a triptan to the treatment regimen, such as sumatriptan or rizatriptan, as recommended by the American College of Physicians 1.

Treatment Options

The following treatment options can be considered:

• Increasing the dosage of an NSAID or acetaminophen without exceeding the recommended maximum daily dose, if the patient is not receiving an adequate dose 1
• Adding a triptan to an NSAID or acetaminophen, if the patient does not achieve sufficient pain relief with an adequate dose of an NSAID or acetaminophen 1
• Using CGRP antagonists-gepants (rimegepant, ubrogepant, or zavegepant) or ergot alkaloid (dihydroergotamine) for moderate to severe acute episodic migraine headache in nonpregnant outpatient adults who do not tolerate or have inadequate response to combination therapy of a triptan and an NSAID or acetaminophen 1
• Using the ditan lasmiditan to treat moderate to severe acute episodic migraine headache in nonpregnant outpatient adults who do not tolerate or have inadequate response to all other pharmacologic treatments included in the guideline 1

Important Considerations

• The choice of a specific NSAID or triptan should be based on individualized decision making, taking into consideration patient preferences on such factors as route of administration and cost 1
• Opioids or butalbital should not be used for the treatment of acute episodic migraine 1
• A nonoral triptan and an antiemetic should be considered in people having severe nausea or vomiting 1
• The patient should be evaluated for use of preventive therapy, and a neurologist consultation is recommended for a comprehensive treatment plan 1

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 a 13-year history of left-sided migraines that have not responded to paracetamol and ibuprofen, sumatriptan can be considered as a treatment option.

• The estimated probability of achieving an initial headache response over the 4 hours following treatment with sumatriptan is depicted in Figure 1 2.
• Sumatriptan tablets were shown to be effective in the acute treatment of migraine headaches in clinical trials 2.
• Patients with migraine-associated nausea, photophobia, and/or phonophobia at baseline had a lower incidence of these symptoms at 2 and 4 hours following administration of sumatriptan tablets compared with placebo 2.

From the Research

Treatment Options for Left-Sided Migraines

Given the 13-year history of left-sided migraines that have not responded to paracetamol and ibuprofen, several alternative treatment options can be considered:

• Triptans: These are highly effective for treating migraine attacks, including those that are severe and have not responded to NSAIDs like ibuprofen 3, 4, 5. Examples include sumatriptan, rizatriptan, and eletriptan.
• Combination Therapies: Combining a triptan with a non-steroidal anti-inflammatory drug (NSAID) has shown better efficacy than using either alone 6. For example, the fixed combination of sumatriptan and naproxen sodium offers improved benefits over monotherapy with each option.
• Dihydroergotamine (DHE): This can be suitable for selected patients, especially those who do not respond well to NSAIDs or triptans alone 5.
• Anti-emetic Drugs: These can be added as necessary to help manage nausea associated with migraines 5.
• Migraine Prophylaxis: For patients experiencing more than 3 attacks per month, or if attacks do not respond to acute treatment, prophylactic treatment may be recommended 3. Substances with proven efficacy include beta-blockers (metoprolol, propranolol), calcium channel blockers (flunarizine), certain 5-HT antagonists, amitriptyline, and antiepileptic drugs (valproic acid, gabapentin, topiramate).

Considerations for Treatment Selection

The choice of treatment should be guided by patient-specific clinical features, including the severity of attacks, response to previous treatments, and the presence of any contraindications 5. It's also important to consider the safety profile of medications, especially in specific populations such as pregnant or breastfeeding women 5.