What is the optimal treatment regimen for a 34-year-old male patient with migraines who is currently taking meloxicam (Mobic) 7.5mg twice a day (BID) and Excedrin (acetaminophen, aspirin, and caffeine) for migraines, but reports inadequate relief?

Optimal Treatment Regimen for Migraines in a 34-Year-Old Male

For this 34-year-old male with inadequate migraine relief, the optimal treatment regimen should include sumatriptan 50mg TID PRN (maximum 9 tablets monthly) for acute attacks, with naproxen 500mg BID PRN as the primary NSAID, and discontinuation of meloxicam. 1, 2

Acute Treatment Strategy

First-Line Therapy: NSAIDs

• Naproxen 500mg BID PRN is an appropriate NSAID choice for this patient
  • Naproxen is specifically recommended by guidelines for migraine treatment 1
  • Discontinuing meloxicam 7.5mg BID and switching to naproxen 500mg BID PRN is appropriate as naproxen has stronger evidence for migraine efficacy 2
  • Adding omeprazole 10mg QAM is prudent to reduce gastrointestinal side effects from NSAID use

Second-Line Therapy: Triptans

• Sumatriptan 50mg TID PRN (maximum 9 tablets monthly) is appropriate when NSAIDs provide inadequate relief
  • The 50mg dose is optimal as clinical trials show similar efficacy between 50mg and 100mg doses with potentially fewer side effects at the lower dose 3
  • Limiting to 9 tablets monthly helps prevent medication overuse headache 1
  • Sumatriptan should be taken at the onset of migraine for maximum effectiveness 2

Combination Therapy

• Excedrin (acetaminophen-aspirin-caffeine) TID PRN (maximum 10 tablets monthly) can be continued
  • This combination has proven efficacy for migraine treatment 2, 4
  • The American College of Physicians specifically recommends this combination 1
  • Limiting to 10 tablets monthly helps prevent medication overuse headache

Treatment Algorithm

1. For mild to moderate attacks:

   • Start with naproxen 500mg
   • If inadequate relief after 2 hours, add Excedrin

2. For moderate to severe attacks:

   • Start with sumatriptan 50mg
   • Can be combined with naproxen for enhanced efficacy
   • Take at first sign of migraine for best results 3

3. For attacks with significant nausea:

   • Consider adding an antiemetic (though not currently in the regimen)
   • Guidelines recommend treating nausea even in patients who are not vomiting 1

Important Considerations

Medication Overuse Prevention

• Limit acute medications to prevent medication overuse headache:
  • NSAIDs: no more than 15 days/month
  • Triptans: no more than 10 days/month 1
  • The current prescription limits (9 sumatriptan tablets, 10 Excedrin tablets monthly) are appropriate

Contraindications and Precautions

• Ensure patient has no contraindications to triptans such as:
  • Uncontrolled hypertension
  • Coronary artery disease
  • Basilar or hemiplegic migraine 2

Monitoring

• Maintain a headache diary to track:
  • Attack frequency, severity, and duration
  • Response to medications
  • Potential triggers 1
  • If attacks occur more than twice weekly, consider preventive therapy

Preventive Therapy Consideration

If the patient continues to have frequent migraines (≥2 attacks/month with ≥3 days of disability) despite optimal acute treatment, or uses acute medications more than twice weekly, preventive therapy should be considered 1, 2.

Common Pitfalls to Avoid

• Using acetaminophen alone (ineffective for migraine) 1
• Not addressing nausea as a component of migraine 1
• Overusing acute medications leading to medication overuse headache 1
• Not providing specific limits on medication use 1