Diagnosis: Migraine Without Aura
This patient meets diagnostic criteria for migraine without aura and should be started on acute treatment with NSAIDs (ibuprofen, diclofenac potassium, or acetylsalicylic acid) as first-line therapy, with triptans as second-line if NSAIDs fail, and does not require neuroimaging given the normal neurological examination and absence of red flags 1.
Diagnostic Reasoning
This presentation is classic for migraine without aura based on ICHD-3 criteria 1:
- Recurrent attacks (every other day for 2 weeks, started 6 months ago)
- Unilateral location (left-sided)
- Duration compatible with 4-72 hour attacks
- Normal neurological examination excluding secondary causes
The patient requires at least 5 attacks fulfilling criteria for formal diagnosis, which appears met given the 6-month history 1. Approximately 40% of migraine patients report bilateral pain, so unilateral presentation is typical but not required 1.
No Neuroimaging Needed
Neuroimaging is not indicated because 2, 3:
- Normal neurological examination
- No red flag features present
- Pattern consistent with primary headache disorder
Red flags that would mandate imaging are absent here 2, 3:
- No thunderclap/sudden worst headache
- No fever or meningeal signs
- No papilledema or focal neurologic deficits
- No impaired consciousness
- Not new headache after age 50
- No trauma history
- No systemic symptoms suggesting secondary cause
Treatment Algorithm
Step 1: First-Line Acute Treatment
Start with NSAIDs 1:
- Ibuprofen (strongest evidence)
- Diclofenac potassium
- Acetylsalicylic acid
- Paracetamol only if NSAID-intolerant (less effective)
Step 2: Second-Line if NSAIDs Fail
Prescribe triptans if over-the-counter analgesics provide inadequate relief 1:
- Most effective when taken early in attack while headache still mild
- Do NOT use during aura phase
- If one triptan fails, try others—individual response varies
- Subcutaneous sumatriptan for rapid peak intensity or vomiting
Step 3: Consider Preventive Therapy
Given the high frequency (every other day = 15+ days/month), evaluate for preventive treatment 4:
Indications for prevention 4:
- Severe debilitating headache despite adequate acute treatment
- Using acute medications more often than recommended (risk of medication overuse headache)
- Contraindications to acute treatment
First-line preventive options (prioritize by cost) 4:
- Topiramate or amitriptyline (most cost-effective)
- Propranolol
- Start low dose, titrate gradually over 2-3 months
Alternative preventive options if first-line fails 4:
- ACE inhibitor (lisinopril)
- ARBs (candesartan, telmisartan)
- SSRI (fluoxetine)
Critical Pitfall: Medication Overuse Headache
Screen for medication overuse 1:
- Headache ≥15 days/month with regular overuse of acute medications >3 months
- Non-opioid analgesics ≥15 days/month
- Triptans or combination analgesics ≥10 days/month
If present, abruptly withdraw overused medication and consider preventive therapy 1.
Patient Education Points
- Migraine is a disease, not just a symptom—provide reassurance about benign nature 1
- Keep headache diary to track frequency, triggers, and treatment response 4
- Lifestyle modifications: regular sleep, hydration, physical activity 4
- Adherence crucial—preventive effects appear gradually over weeks 4
- Avoid unnecessary trigger avoidance that damages quality of life 1
When to Refer
Specialist referral indicated if 1:
- Progression to chronic migraine (≥15 headache days/month for >3 months with ≥8 migraine days)
- Inadequate response to multiple preventive trials
- Medication overuse headache requiring specialized management