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

Optimal Migraine Treatment for a 34-Year-Old Male

For this 34-year-old male with inadequate migraine relief, I recommend discontinuing meloxicam, starting naproxen 500mg BID PRN, prescribing sumatriptan 50mg TID PRN (maximum 9 tablets monthly), continuing Excedrin TID PRN (maximum 8 tablets weekly), and adding omeprazole 10mg daily for gastroprotection. 1

Rationale for Medication Changes

NSAID Selection

• Naproxen 500mg BID PRN is superior to meloxicam for migraine treatment, with stronger evidence for efficacy 1
• Naproxen provides effective relief for mild to moderate attacks and can be combined with other medications for enhanced efficacy 1
• Adding omeprazole 10mg daily is appropriate for gastroprotection with regular NSAID use 1

Acute Medications

• Sumatriptan 50mg is an optimal dose with similar efficacy but potentially fewer side effects compared to 100mg 1, 2
  • FDA data shows no evidence that doses above 50mg provide greater effect than 50mg 2
  • Limiting to 9 tablets monthly helps prevent medication overuse headache 1
• Excedrin (acetaminophen-aspirin-caffeine) is specifically recommended by guidelines for migraine treatment 1
  • Limiting to 8 tablets weekly (approximately 32 tablets monthly) is well within safety parameters to prevent medication overuse headache 1

Treatment Algorithm

For Mild to Moderate Attacks:

1. Start with naproxen 500mg
2. If inadequate relief after 2 hours, add Excedrin 1

For Moderate to Severe Attacks:

1. Start with sumatriptan 50mg
2. Can combine with naproxen 500mg for enhanced efficacy 1

Medication Limits to Prevent Overuse Headache

• Sumatriptan: Maximum 9 tablets monthly (less than 10 days/month) 1
• Excedrin: Maximum 8 tablets weekly (approximately 32 tablets monthly, well within the 15 days/month limit) 1
• Naproxen: Use PRN, not exceeding 15 days/month 1

Important Considerations

Precautions with Triptans

• Ensure patient has no contraindications to sumatriptan:
  • No uncontrolled hypertension
  • No coronary artery disease
  • No basilar or hemiplegic migraine 1

Monitoring and Follow-up

• Patient should maintain a headache diary to track:
  • Attack frequency, severity, and duration
  • Response to medications
  • Potential triggers 1

Consider Preventive Therapy

• If attacks continue to occur more than twice weekly despite this optimized acute treatment regimen
• If patient uses acute medications more than twice weekly
• If patient experiences ≥2 attacks/month with ≥3 days of disability 1

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

This treatment plan follows evidence-based guidelines for migraine management, optimizing acute therapy while setting appropriate limits to prevent medication overuse headache.