What is the best NSAID (Non-Steroidal Anti-Inflammatory Drug) and dosage for a severe migraine attack in a patient taking amitriptyline?

Best NSAID for Severe Migraine Attack

Ibuprofen 400-600mg is the first-line NSAID treatment for severe migraine attacks, to be taken as early as possible during the headache phase. 1

First-Line Treatment: NSAIDs

The most recent guidelines recommend NSAIDs as first-line medication for acute migraine treatment:

• Ibuprofen: 400-600mg orally at onset of headache 1
• Naproxen sodium: 500-550mg orally 1
• Diclofenac potassium: Recommended as effective 2
• Aspirin: 800-1000mg orally 1

Important Considerations for This Patient

Since the patient is taking amitriptyline (likely as a preventive medication), it's important to note that this doesn't contraindicate NSAID use. However, be aware that:

• NSAIDs should be used early in the headache phase for maximum effectiveness 2
• For patients with significant nausea/vomiting during attacks, add a prokinetic antiemetic such as domperidone or metoclopramide 2
• Limit NSAID use to no more than 15 days per month to prevent medication overuse headache 1

Second-Line Treatment: Triptans

If NSAIDs don't provide adequate relief:

• Sumatriptan: 50mg orally for moderate attacks; 6mg subcutaneously for severe attacks or those with significant nausea/vomiting 1
• Rizatriptan: 10mg orally (for patients ≥40kg) 1

Combination Therapy

For particularly severe or difficult-to-treat migraines:

• Combining triptans with fast-acting NSAIDs can be more effective and help prevent recurrence 2, 3
• A study showed that adding naproxen sodium 550mg to sumatriptan significantly decreased migraine recurrence from 59% to 25.5% 3

Third-Line Options

If both NSAIDs and triptans fail or are contraindicated:

• Ditans (lasmiditan) or Gepants (ubrogepant, rimegepant) 2, 1
• Note that lasmiditan users should not operate machinery for at least 8 hours after intake 2

Medications to Avoid

• Oral ergot alkaloids: Poorly effective and potentially toxic 2
• Opioids and barbiturates: Questionable efficacy, considerable adverse effects, and risk of dependency 2, 1

Treatment Algorithm

1. Start with ibuprofen 400-600mg at the earliest sign of migraine
2. If inadequate response within 2 hours, consider adding a triptan
3. For severe attacks with significant nausea/vomiting, add an antiemetic or consider subcutaneous sumatriptan 6mg
4. For recurrent attacks, consider combination therapy with NSAID plus triptan
5. For patients who fail both NSAIDs and triptans, consider ditans or gepants

Monitoring and Follow-up

• Track headache frequency, severity, and response to treatment using a headache calendar 1
• Limit acute medication use to prevent medication overuse headache (NSAIDs: no more than 15 days per month) 1
• Consider preventive therapy if experiencing frequent attacks despite optimized acute therapy 2

Remember that timely use with the correct dose is crucial for effectiveness, and frequent repeated use of acute medication risks development of medication overuse headache 2.