What is the best treatment approach for a 48-year-old male complaining of migraines?

Treatment Approach for a 48-Year-Old Male with Migraines

For a 48-year-old male with migraines, the first-line treatment should be nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin, ibuprofen, or naproxen sodium, with triptans reserved for moderate to severe attacks or when NSAIDs fail to provide relief. 1

Acute Treatment Algorithm

Step 1: First-Line Therapy (Mild to Moderate Attacks)

• NSAIDs:
  • Ibuprofen 400-800 mg every 6 hours (maximum 2.4g daily)
  • Naproxen sodium 275-550 mg every 2-6 hours (maximum 1.5g daily)
  • Aspirin 650-1000 mg every 4-6 hours (maximum 4g daily)
  • Combination of acetaminophen + aspirin + caffeine

Note: Acetaminophen alone is not recommended for migraine as evidence shows it is ineffective 1

Step 2: Second-Line Therapy (Moderate to Severe Attacks or First-Line Failure)

• Triptans:
  • Sumatriptan 50-100 mg orally
  • Rizatriptan 5-10 mg orally
  • Zolmitriptan 2.5-5 mg orally
  • Naratriptan 1-2.5 mg orally

The FDA data shows that sumatriptan provides headache relief in 50-62% of patients within 2 hours compared to 17-27% with placebo 2

Step 3: For Attacks with Significant Nausea/Vomiting

• Use non-oral routes of administration:
  • Sumatriptan subcutaneous injection (6 mg)
  • Sumatriptan nasal spray
  • DHE nasal spray
• Add an antiemetic:
  • Metoclopramide 10 mg
  • Prochlorperazine

Preventive Treatment Evaluation

Evaluate the need for preventive therapy if the patient has:

1. Two or more attacks per month with disability lasting ≥3 days/month
2. Failure of or contraindication to acute treatments
3. Use of abortive medication more than twice per week
4. Presence of uncommon migraine conditions (hemiplegic migraine, migraine with prolonged aura)

First-Line Preventive Options:

• Propranolol (80-240 mg/day)
• Timolol (20-30 mg/day)
• Amitriptyline (30-150 mg/day)
• Divalproex sodium (500-1500 mg/day)
• Sodium valproate (800-1500 mg/day)

Important Clinical Considerations

Medication Overuse Risk

• Limit acute therapy to no more than twice per week to prevent medication-overuse headache 1
• Medication overuse can lead to increasing headache frequency and potentially daily headaches

Treatment Timing

• Triptans are most effective when taken early in an attack while pain is still mild 1
• Do not use triptans during the aura phase of a migraine attack

Rescue Medication

• For severe attacks not responding to other treatments, consider a self-administered rescue medication
• Use opioids cautiously and only when other medications cannot be used or when sedation effects are not a concern 1

Patient Education

• Maintain a headache diary to track:
  • Attack frequency, severity, and duration
  • Resulting disability
  • Response to treatment
  • Adverse effects of medication

Potential Pitfalls to Avoid

1. Overuse of medication: Using acute medications more than 2 days per week can lead to medication-overuse headache
2. Inadequate trial of preventive medications: Preventive medications may take 2-3 months to show benefit
3. Using acetaminophen alone: Evidence shows it's ineffective for migraine 1
4. Failure to address nausea: Nausea is one of the most disabling symptoms and should be treated appropriately
5. Not considering non-oral routes when needed: For patients with significant nausea/vomiting, non-oral routes are essential

By following this structured approach to migraine management, focusing on both acute and preventive strategies, the patient's migraine burden can be significantly reduced, improving quality of life and reducing disability.