What medication can be given to a patient with a history of stroke presenting with severe migraine-like symptoms similar to their previous migraines?

Management of Severe Migraine in a Patient with Stroke History

For a patient with stroke history experiencing severe migraine similar to previous migraines, NSAIDs are the first-line treatment, with careful consideration of contraindications related to their stroke history. 1

Initial Assessment

• Confirm that the headache is consistent with the patient's previous migraine pattern and not a new stroke presentation 1
• Evaluate for "red flags" that might indicate a stroke rather than migraine (inconsistent neurological findings, new onset symptoms, progressive worsening) 1
• Consider that migraine can be both a stroke mimic and a stroke risk factor 2, 3

First-Line Treatment Options

• NSAIDs are recommended as first-line treatment for migraine attacks in most patients, including those with stroke history 1
  • Options include aspirin, ibuprofen, naproxen sodium, or the acetaminophen-aspirin-caffeine combination 1
  • These medications should be administered as early as possible during the attack for maximum efficacy 1

Special Considerations for Stroke Patients

• Avoid triptans in patients with stroke history due to theoretical risks of cerebral vasoconstriction and ischemia 1
• Avoid ergot derivatives as they may increase stroke risk 1, 3
• Avoid opioids when possible due to risk of dependency, rebound headaches, and eventual loss of efficacy 1

Alternative Treatment Approaches

• Antiemetics such as metoclopramide or prochlorperazine can be effective for both pain relief and treatment of associated nausea 1
• Non-pharmacological approaches such as rest in a dark, quiet room may provide additional relief 1

For Severe, Refractory Migraine

• Ketorolac (Toradol) parenteral administration can be considered for severe migraine attacks when other treatments fail 1
• If absolutely necessary, a rescue medication may be considered with careful monitoring 1

Long-Term Management

• Consider preventive treatments to reduce migraine frequency in patients with stroke history 1
• Options include amitriptyline, sodium valproate, or calcium channel antagonists (particularly verapamil) with aspirin if there are no contraindications 1
• Avoid β-blockers in patients with stroke history as they might worsen intracranial vasoconstriction 1

Important Cautions

• Monitor use of analgesics closely as overuse may lead to rebound headaches 1
• Limit acute treatment to no more than twice weekly to prevent medication-overuse headaches 1
• For women with migraine and stroke history, avoid oral contraceptives containing estrogen 1

Remember that distinguishing between migraine and stroke can be challenging, especially in patients with a history of both conditions. When in doubt, prioritize ruling out a new stroke before treating as a migraine 2, 3.