What is the appropriate management and treatment for Rebekah's recurrent migraine symptoms?

Management of Rebekah's Migraine Symptoms

Rebekah should be treated with a triptan (such as sumatriptan 50 mg) combined with an NSAID (such as ibuprofen 400-600 mg) taken as early as possible during her migraine attack to effectively manage her symptoms and restore her ability to function. 1

Initial Assessment

• Evaluate Rebekah's migraine characteristics:
  • Frequency and duration of headaches
  • Pain characteristics (throbbing, pulsating)
  • Associated symptoms (nausea, photophobia, phonophobia)
  • Functional impairment (as mentioned in her case)
  • Previous treatments and their effectiveness
  • Potential triggers (foods, stress, sleep patterns, hormonal factors)
  • Family history of migraines 2, 1

Acute Treatment Recommendations

First-line Treatment

1. Combination therapy:

   • Sumatriptan 50 mg (oral) + ibuprofen 400-600 mg
   • Take at first sign of migraine while pain is still mild 1
   • Clinical trials show sumatriptan 50 mg is effective with 50-61% of patients achieving headache response within 2 hours and 68-78% within 4 hours 3
   • No additional benefit from 100 mg dose compared to 50 mg 3

2. Alternative first-line options (if above not suitable):

   • Naproxen sodium 500-550 mg
   • Rizatriptan 10 mg (if ≥40kg) 1

Second-line Treatment

If first-line treatment fails:

• Try a different triptan (triptans vary in effectiveness between individuals) 1
• For severe attacks with significant nausea/vomiting: sumatriptan 6 mg subcutaneously 1

Third-line Treatment

If triptans are contraindicated or ineffective:

• Ditans (lasmiditan) or gepants (ubrogepant, rimegepant) 1

Medication Limitations to Prevent Overuse

• Sumatriptan: No more than 9 days per month
• NSAIDs: No more than 15 days per month
• OTC medications: No more than 14 days per month 1

Non-Pharmacological Approaches

• Regular sleep schedule
• Adequate hydration
• Identification and avoidance of triggers
• Regular aerobic exercise
• Relaxation techniques or mindfulness 1

Documentation and Follow-up

1. Sick certificate provision as requested
2. Headache diary: Provide Rebekah with a headache diary to track:
   • Frequency and severity of attacks
   • Medication use and effectiveness
   • Potential triggers
3. Follow-up appointment in 2-3 weeks to evaluate treatment response 1

Preventive Treatment Consideration

If Rebekah experiences:

• Two or more migraine attacks per month with disability lasting 3+ days
• Failure of acute treatments
• Use of abortive medication more than twice per week

Consider preventive options:

• Beta-blockers (e.g., propranolol) as first-line
• CGRP monoclonal antibodies for episodic or chronic migraine 1

Important Cautions

• Avoid opioids and barbiturates due to risk of medication overuse headache 4
• Triptans are contraindicated in patients with coronary artery disease, uncontrolled hypertension, or history of stroke
• Valproate has an absolute contraindication in women of childbearing age 1

Referral Indications

Consider referral to a neurologist if:

• Inadequate response to first-line treatments
• Presence of neurological red flags
• Need for complex preventive therapy 1