What is the first-line treatment for a patient with a history of migraine presenting with symptoms of headache, photophobia, tinnitus, and nausea?

First-Line Treatment for Acute Migraine

For most migraine sufferers, including this patient with classic symptoms of headache, photophobia, tinnitus, and nausea, non-steroidal anti-inflammatory drugs (NSAIDs) are the first-line treatment. 1

Treatment Algorithm for Acute Migraine

Step 1: First-Line Therapy - NSAIDs

• The patient has already tried naproxen (an NSAID) without relief, indicating treatment failure with first-line therapy
• Evidence consistently supports the efficacy of aspirin, ibuprofen, naproxen sodium, and the combination of acetaminophen-aspirin-caffeine for acute migraine treatment 1
• Acetaminophen alone (which the patient has also tried) is ineffective for migraine 1

Step 2: Second-Line Therapy - Triptans

Since the patient has failed NSAID therapy, a triptan should be the next treatment:

• Recommended triptan options:

  • Oral sumatriptan 50-100 mg (evidence shows doses of 50 mg and 100 mg may provide greater effect than 25 mg) 2
  • Oral rizatriptan
  • Oral zolmitriptan
  • Oral naratriptan

• For this patient with significant nausea, consider:

  • Non-oral route: Subcutaneous sumatriptan 6 mg (70-80% headache relief at 1 hour) 3
  • Intranasal sumatriptan
  • Add an antiemetic to treat the nausea 1

Evidence for Triptan Efficacy

• Clinical trials demonstrate that oral sumatriptan provides headache relief in 50-67% of patients at 2 hours compared to 10-31% with placebo 3
• Subcutaneous sumatriptan achieves headache relief in 70-80% of patients at 1 hour 3
• FDA data shows sumatriptan tablets provide significantly greater headache response than placebo at both 2 and 4 hours 2

Important Considerations

Contraindications for Triptans

• Do not use triptans in patients with:
  • Uncontrolled hypertension
  • Basilar or hemiplegic migraine
  • Risk factors for heart disease
  • Ischemic heart disease or history of myocardial infarction 1

Medication Overuse Headache Risk

• Limit acute treatment to no more than twice per week to prevent medication-overuse headache 1
• Consider preventive therapy if:
  • Patient has ≥2 migraine attacks per month with ≥3 days of disability
  • Patient uses rescue medication more than twice weekly
  • Patient has failed acute treatments 1

Dosing Guidelines

• If migraine doesn't resolve within 2 hours of taking sumatriptan or returns after improvement, a second dose may be administered at least 2 hours after the first dose
• Maximum daily dose: 200 mg in a 24-hour period 2
• For patients with hepatic impairment, maximum single dose should not exceed 50 mg 2

Follow-up Recommendations

• Track response to treatment with a headache diary
• Document attack frequency, severity, duration, disability, response to treatment, and medication side effects
• Identify and avoid potential migraine triggers

For this patient with persistent migraine not responding to naproxen or acetaminophen, a triptan (preferably via non-oral route due to significant nausea) represents the most appropriate next step in treatment.