Management of Acute Migraine Headache
For this patient's headache, I recommend starting with NSAIDs such as ibuprofen or naproxen for mild to moderate attacks, and a triptan + NSAID combination for moderate to severe attacks, administered as early as possible after migraine onset. 1
Initial Assessment and Diagnosis
When evaluating a patient with headache, it's crucial to first determine whether this is a primary headache disorder or a secondary headache caused by an underlying condition. Look specifically for these red flags:
- Sudden onset ("thunderclap" headache)
- Headache worsened by Valsalva maneuver
- Headache that awakens patient from sleep
- New onset in an older person
- Progressive worsening pattern
- Neurological deficits or abnormal findings on examination
- Headache during sexual activity
- Headache associated with fever, neck stiffness, or rash 2, 1, 3
If any of these red flags are present, neuroimaging should be considered to rule out secondary causes 2.
Treatment Algorithm for Migraine Headache
Step 1: Mild to Moderate Migraine
- First-line: NSAIDs (ibuprofen 400-800mg, naproxen 500-550mg, aspirin 900-1000mg)
- Alternative: Combination analgesics (acetaminophen + aspirin + caffeine) 1
Step 2: Moderate to Severe Migraine
- First-line: Triptan + NSAID combination (start as early as possible)
- Options: Sumatriptan 50-100mg PO (avoid in patients with coronary artery disease) 1, 4
Step 3: For Patients Who Don't Respond to Triptans
- CGRP antagonists (gepants) such as ubrogepant 50-100mg (maximum 200mg/24 hours) 1
Step 4: For Refractory Migraine
- Ketorolac (Toradol), a parenteral NSAID with rapid onset and 6-hour duration 2
Important Considerations and Cautions
Medication Overuse Risk
Frequent use of migraine medications (ergotamine, triptans, opioids, or combination analgesics for 10+ days per month) can lead to medication overuse headache, presenting as daily headaches or increased frequency of migraine attacks 4. Limit acute treatments to prevent this complication.
Contraindications for Triptans
Avoid triptans in patients with:
- Coronary artery disease
- Prinzmetal's variant angina
- Uncontrolled hypertension
- History of stroke or TIA
- Wolff-Parkinson-White syndrome 4
Preventive Treatment
Consider preventive therapy if the patient experiences more than two headaches per week. Options include:
- Beta-blockers (propranolol 80-240 mg/day)
- Anticonvulsants (topiramate 100 mg/day)
- Antidepressants (amitriptyline 30-150 mg/day) 2, 1
Special Situations
Pregnancy
Acetaminophen (650-1000mg every 4-6 hours, maximum 4g/day) is the first-line treatment for acute migraine attacks during pregnancy 1.
Chronic Migraine
For patients with chronic migraine (≥15 headache days/month for >3 months, with ≥8 days having migraine features), onabotulinumtoxinA is FDA-approved for prophylaxis 2.
Avoid These Common Pitfalls
Using opioids for chronic headaches - can lead to dependency, rebound headaches, and eventual loss of efficacy 2
Using acetaminophen alone - not effective for migraine when used alone, but works in combination with aspirin and caffeine 2
Failing to recognize medication overuse headache - frequent use of acute migraine medications can paradoxically increase headache frequency 4
Missing secondary causes - always evaluate for red flags that might indicate a serious underlying condition 3
By following this approach, you can effectively manage this patient's migraine headache while minimizing complications and optimizing outcomes.