What is the treatment for a complex migraine?

Treatment for Complex Migraine

For complex migraine, the first-line treatment is a combination of a triptan (such as sumatriptan 50mg) with an NSAID (such as naproxen 500mg), along with an antiemetic if nausea is present. 1

Understanding Complex Migraine

Complex migraine typically refers to migraine with aura or other neurological symptoms. It's important to differentiate it from migrainous infarction, which is defined as a migraine attack with aura symptoms persisting for >60 minutes with evidence of ischemic infarct on neuroimaging 2.

Acute Treatment Algorithm

First-Line Treatment

• Combination therapy: Triptan + NSAID
  • Sumatriptan 50mg + Naproxen 500mg 1
  • Take medication early in the headache phase for maximum effectiveness 3
  • Add metoclopramide 10mg or domperidone if nausea is present 3, 1

For Inadequate Response (after 2 hours)

• Consider non-oral routes of administration:
  • Sumatriptan subcutaneous injection 6mg
  • Sumatriptan intranasal spray
  • Dihydroergotamine (DHE) nasal spray 1

For Contraindications to Triptans

• NSAID monotherapy (naproxen 500mg)
• Add antiemetic for nausea 1
• Triptans are contraindicated in:
  • Uncontrolled hypertension
  • Coronary artery disease
  • Basilar or hemiplegic migraine
  • Within 24 hours of ergotamine use 1

Medication Usage Limits

• Limit triptan use to no more than 9 days per month
• Limit NSAID use to no more than 15 days per month
• Limit acute therapy to no more than twice per week to prevent medication-overuse headache 1

For Status Migrainosus (prolonged attack >72 hours)

• IV hydration if dehydrated
• Dexamethasone 10mg IV/IM as a single dose
• Naratriptan 2.5mg twice daily (off-label) 1

Preventive Treatment

Consider preventive therapy if:

• Two or more attacks per month with disability lasting 3 or more days per month
• Contraindication to or failure of acute treatments
• Use of abortive medication more than twice per week
• Presence of uncommon migraine conditions (hemiplegic migraine, migraine with prolonged aura, or migrainous infarction) 3, 1

First-Line Preventive Medications

• 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) 3, 1

Common Pitfalls to Avoid

1. Using acetaminophen alone - Ineffective for migraine treatment 1
2. Not addressing nausea - Nausea is one of the most disabling symptoms and should be treated appropriately 3, 4
3. Overusing acute medications - Can lead to medication overuse headache 3, 1
4. Using oral ergot alkaloids, opioids, or barbiturates - These are poorly effective, potentially toxic, and should be avoided 3
5. Not considering non-oral routes when oral medication is ineffective or when significant nausea/vomiting is present 1
6. Inadequate trial of preventive medications - Efficacy may take 2-3 months to manifest 3, 1

Remember that treatment efficacy for preventive therapy should be assessed after 2-3 months for oral medications, 3-6 months for CGRP monoclonal antibodies, and 6-9 months for onabotulinumtoxinA 3.