From the Guidelines
For a 97-year-old male with left-sided headache who is on digoxin, cannot take NSAIDs, and has no relief from acetaminophen, I recommend adding a triptan to acetaminophen as the next step in management, considering the patient's contraindication to NSAIDs. This approach is based on the guideline from the American College of Physicians, which suggests adding a triptan to an NSAID or acetaminophen when NSAIDs are contraindicated or not tolerated 1. Given the patient's age and medication profile, it's essential to choose a triptan with a favorable side effect profile and consider factors such as route of administration and cost.
Some key points to consider in the management of this patient include:
- The patient is already on a maximum dose of acetaminophen, so increasing the dose is not an option
- The use of opioids, such as tramadol or oxycodone, is not recommended for the treatment of acute episodic migraine due to the risk of dependence and other adverse effects 1
- The patient's digoxin therapy should be monitored closely, as some triptans may interact with digoxin
- A thorough evaluation of the headache's cause is crucial, including assessment for temporal arteritis, which would require immediate corticosteroid treatment
- Regular follow-up to assess efficacy and side effects is important, with dose adjustments made accordingly
In terms of specific triptan options, sumatriptan or rizatriptan may be considered, given their established efficacy and safety profiles. However, the choice of triptan should be individualized based on patient preferences and factors such as route of administration and cost. Additionally, consideration should be given to using a nonoral triptan and an antiemetic in people having severe nausea or vomiting. Overall, a stepwise approach to management, with careful monitoring and adjustment of therapy as needed, is essential to optimize outcomes in this patient.
From the Research
Treatment Options for Left-Sided Headache
Given the patient's age and medication regimen, including digoxin, and the inability to use NSAIDs, the following treatment options can be considered:
- The patient is already on 650mg acetaminophen (Tylenol) three times a day (TID) with no relief, so alternative treatments need to be explored 2.
- Triptans, such as sumatriptan, rizatriptan, or zolmitriptan, could be considered, but their use with other medications, especially those with a narrow therapeutic range like digoxin, should be carefully evaluated to avoid potential drug-drug interactions 3.
- Ergotamines, like dihydroergotamine (DHE), might be suitable for selected patients, but caution is advised due to potential interactions and the patient's age 4, 2.
- Corticosteroids, such as prednisone, have been used in the treatment of medication-overuse headache and could be considered for a short course to help manage the patient's headache, especially if there's suspicion of medication overuse headache 5.
- Antiemetic drugs can be added as necessary to help manage associated symptoms like nausea and vomiting 2.
Considerations and Precautions
When selecting a treatment, it's crucial to consider the patient's specific clinical features, the severity of the headache, and potential interactions with existing medications like digoxin 3, 2.
- The risk of medication overuse headache (MOH) should be considered, especially if the patient is taking medications frequently for headache relief. MOH diagnosis can only be confirmed after cessation of the suspected medication and observation of headache patterns over time 6.
- A comprehensive approach to managing the patient's headache may include a bridging or transition program, nonpharmacological measures, and prophylactic medication started early in the treatment course, after any offending medication is discontinued 6.