What is the next best step for a 75-year-old patient with a persistent migraine (headache) for 8 days, despite initial treatment with Decadron (dexamethasone) and Toradol (ketorolac) in the emergency room (ER)?

Management of Persistent Migraine in a 75-Year-Old Patient

For a 75-year-old patient with persistent migraine for 8 days despite treatment with Decadron and Toradol in the ER, the next best step is to initiate triptan therapy (such as sumatriptan 50mg) combined with an NSAID (such as naproxen), as this combination provides superior efficacy for breaking persistent migraine attacks. 1, 2

Assessment of Current Situation

This case represents a persistent migraine that has not responded to initial emergency treatment with:

• Dexamethasone (Decadron) - a corticosteroid used to reduce inflammation and prevent migraine recurrence
• Ketorolac (Toradol) - an NSAID used for acute pain relief

The persistence of symptoms for 8 days despite these interventions indicates a status migrainosus (a migraine lasting >72 hours), which requires more aggressive management.

Treatment Algorithm

First-line Treatment (Immediate)

1. Triptan + NSAID combination therapy:

   • Sumatriptan 50mg orally (can increase to 100mg if needed) 3
   • Combined with naproxen 500mg 1, 2
   • This combination has shown superior efficacy compared to either medication alone

2. Consider non-oral route if significant nausea/vomiting:

   • Sumatriptan nasal spray or injection 2
   • Add an antiemetic if needed 2

If First-line Treatment Fails (within 24 hours)

1. Consider rescue medication:

   • A second dose of triptan can be given after 2 hours if needed (not exceeding 200mg/24 hours) 3, 4
   • Avoid opioids and butalbital-containing compounds as they can lead to medication overuse headache 1, 2

2. Consider CGRP antagonist (gepant):

   • Rimegepant, ubrogepant, or zavegepant if triptans are ineffective 1, 2
   • These are newer options with evidence supporting efficacy

Prevention of Recurrence

1. Initiate preventive therapy since this patient has:

   • A prolonged attack (8 days)
   • Failed acute treatments
   • Likely significant disability from the prolonged attack 2

2. Options for preventive therapy (to be started concurrently with acute treatment):

   • Propranolol 80-240 mg/day (consider lower doses in elderly)
   • Amitriptyline 10-25mg at bedtime (start low in elderly)
   • Topiramate 25-100 mg/day (titrate slowly)
   • Candesartan 8-32 mg daily (beneficial if hypertension is present) 2

Special Considerations for Elderly Patients

1. Cardiovascular risk assessment:

   • Triptans should be used with caution in elderly patients due to potential cardiovascular effects
   • Consider lower initial doses (25-50mg of sumatriptan rather than 100mg) 3

2. Medication interactions:

   • Review current medications for potential interactions with migraine treatments
   • Avoid combining triptans with SSRIs/SNRIs if possible due to serotonin syndrome risk 3

3. Renal/hepatic function:

   • Consider dose adjustments based on organ function
   • For hepatic impairment, maximum sumatriptan dose should not exceed 50mg 4

Lifestyle Modifications

Concurrent with pharmacological treatment, advise:

• Regular sleep schedule
• Adequate hydration
• Identification and avoidance of personal triggers
• Stress management techniques 2

When to Consider Hospitalization

If the patient fails to respond to the above treatments, consider hospitalization for:

• Intravenous hydration
• Parenteral medications
• Monitoring for complications 5

Pitfalls to Avoid

1. Medication overuse headache:

   • Limit acute medications to ≤10 days/month for triptans and ≤15 days/month for NSAIDs 2
   • This is particularly important to address in this case given the prolonged nature of the headache

2. Undertreatment:

   • Inadequate dosing or inappropriate medication selection can lead to continued suffering
   • The stratified care approach (matching treatment intensity to headache severity) is more effective than step care for severe migraines 6

3. Ignoring preventive therapy:

   • This prolonged attack indicates the need for preventive therapy to reduce frequency and severity of future attacks 1, 2

4. Overlooking red flags:

   • New-onset migraine in an elderly patient warrants consideration of secondary causes
   • Ensure thorough evaluation has been completed 2

The evidence strongly supports using combination therapy with a triptan and NSAID as the most effective approach for breaking a persistent migraine attack, while simultaneously initiating preventive therapy to reduce future occurrences.