What can be used in the acute management of a 25-year-old female patient with frequent, severe, unilateral, photophobic, and phonophobic headaches, accompanied by nausea and vomiting, and lasting 3-4 hours?

Acute Management of Migraine

Triptan (option C) is the most appropriate treatment for acute management of this patient's migraine headache. 1

Clinical Presentation Analysis

This 25-year-old female presents with classic migraine features:

• Unilateral, throbbing headache
• Photophobia and phonophobia
• Nausea and vomiting
• Normal brain CT (ruling out secondary causes)
• Frequent attacks (5 times per week)
• Moderate-to-severe intensity (based on associated symptoms)
• 3-4 hour duration

Treatment Rationale

Triptans are the first-line treatment for acute moderate-to-severe migraine attacks based on the following evidence:

• The American Academy of Neurology and American College of Physicians recommend oral triptans as first-line treatment for acute migraine attacks 1
• Triptans are 5-HT1 receptor-specific agonists that are effective in 70-82% of patients 2
• For patients with significant nausea/vomiting (as in this case), non-oral formulations of triptans (nasal sprays, injections) may be particularly beneficial 1
• Triptans have been shown to be more effective than ergots and equal or better than NSAIDs, ASA (aspirin), and acetaminophen for 2-hour headache relief 3

Comparison with Other Options

A. Aspirin (ASA)

• While aspirin 1000mg can be used for acute migraine treatment 1, it's generally less effective than triptans for moderate-to-severe migraines with significant associated symptoms like nausea and vomiting 3
• Given the severity of this patient's symptoms and frequency of attacks, a triptan would be more appropriate

B. Beta-blocker

• Beta-blockers such as propranolol (80-240 mg/day) are recommended for preventive therapy, not acute management 1
• They would not provide immediate relief for an ongoing migraine attack

C. Triptan

• Triptans provide relief in 42-76% of patients within 2 hours 3
• Particularly effective for moderate-to-severe migraines with associated symptoms 1
• The presence of nausea and vomiting may warrant consideration of non-oral formulations 1

D. 100% Oxygen

• Oxygen therapy is primarily indicated for cluster headaches, not migraine 1
• Not mentioned in any of the guidelines as a treatment for acute migraine

Clinical Evidence Supporting Triptans

• Sumatriptan has been shown to provide headache relief in 50-62% of patients within 2 hours and 68-79% within 4 hours 4
• Triptans also effectively reduce associated symptoms like nausea, photophobia, and phonophobia 4
• Subcutaneous sumatriptan reaches peak blood concentrations in approximately 15 minutes, making it the fastest-acting option for severe attacks 2

Important Considerations

• Triptans are contraindicated in patients with ischemic heart disease, uncontrolled hypertension, or other significant cardiovascular disease 1
• Limit acute medications to no more than 2 days per week to prevent medication-overuse headache 1
• If one triptan is ineffective, a different triptan should be tried before abandoning this line of therapy 2
• Adding an antiemetic (e.g., metoclopramide 10mg) may be beneficial for this patient due to her nausea and vomiting 1

Conclusion

Given the patient's presentation with moderate-to-severe migraine with associated symptoms, a triptan is the most appropriate choice for acute management. The presence of nausea and vomiting may warrant consideration of a non-oral formulation for optimal efficacy.