What is the best approach to manage migraines in a 54-year-old male patient who had retinal detachment surgery last month?

Management of Migraines in a Patient After Retinal Detachment Surgery

NSAIDs should be used as first-line treatment for migraines in this 54-year-old male patient who recently underwent retinal detachment surgery, with triptans as second-line therapy if NSAIDs fail to provide adequate relief. 1

First-Line Treatment Approach

NSAIDs

• Ibuprofen (400-800mg), naproxen (500mg), or aspirin (900mg) are recommended first-line options 1
• These medications have strong evidence supporting their efficacy for migraine relief
• Take early in the attack when pain is still mild to moderate for best results 2

Alternative First-Line Option

• Acetaminophen (1000mg) if NSAIDs are contraindicated or not tolerated 1
• Note that acetaminophen has somewhat less efficacy than NSAIDs but remains a viable option 2

Second-Line Treatment Options

If first-line treatment fails to provide adequate relief:

Triptans

• Sumatriptan (25-100mg) has demonstrated significant efficacy with 52-62% of patients achieving headache response within 2 hours 3
• Other triptans (rizatriptan, zolmitriptan) may be considered if one triptan is ineffective 2, 1
• Triptans are most effective when taken early in an attack while pain is still mild 2

Important Considerations for This Patient

• Given recent retinal detachment surgery, carefully monitor for any visual changes or eye pain
• Triptans may cause vasospasm, so use with caution in this patient with recent ocular surgery 3
• Avoid medication overuse (limit acute medications to <10 days/month for triptans and <15 days/month for NSAIDs) to prevent medication overuse headache 1

Treatment Algorithm

1. Start with ibuprofen 400-800mg or naproxen 500mg at first sign of migraine
2. If inadequate relief after 2 hours, consider:
   • Taking a second dose of NSAID (within daily maximum limits)
   • Adding an antiemetic if nausea is present
3. For subsequent attacks with poor response to NSAIDs:
   • Switch to a triptan (sumatriptan 50mg)
   • Consider combination therapy (triptan + NSAID) for enhanced efficacy 1

Preventive Therapy Considerations

If migraines occur frequently (≥2 attacks/month) or cause significant disability:

• Consider preventive therapy with one of the following 1:
  • Propranolol (80-240 mg/day)
  • Amitriptyline (30-150 mg/day)
  • Topiramate (50-200 mg/day)
• Assess efficacy after 2-3 months of consistent use

Special Considerations and Pitfalls

• Medication overuse risk: Limit use of all acute medications to prevent medication overuse headache 2, 1
• Post-surgical timing: Since surgery was just last month, consider potential relationship between surgery and headaches
• Avoid vasoconstrictive agents if there are concerns about retinal blood flow after surgery
• Monitor for visual changes that could indicate surgical complications rather than migraine

When to Refer to Specialist

• If headaches occur more than twice weekly
• If patient uses acute medications more than twice weekly
• If current management fails to provide adequate relief after 2-3 trials of different medications 1