What treatment options are available for a patient under 40 with migraines that do not respond to typical treatments such as Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), antiemetics, and triptan medication?

Treatment Options for Migraine Not Responding to NSAIDs, Antiemetics, and Triptans in Patients Under 40

For patients under 40 with migraines that do not respond to NSAIDs, antiemetics, and triptans, CGRP antagonists (gepants) or dihydroergotamine should be considered as the next line of treatment. 1, 2

Next-Line Treatment Options

• CGRP antagonists (gepants) including rimegepant, ubrogepant, or zavegepant are recommended for moderate to severe migraine headaches that don't respond to first-line treatments 1, 2
• Dihydroergotamine (DHE), particularly in intranasal formulation, has good evidence for efficacy and safety in treating refractory migraines 2, 3
• The ditan lasmiditan can be considered when patients don't respond to other pharmacologic treatments, though it should be reserved for cases where other options have failed 1

Treatment Algorithm for Refractory Migraine

1. First alternative option: Try CGRP antagonists (gepants) such as rimegepant, ubrogepant, or zavegepant 1, 2
2. Second alternative option: Consider dihydroergotamine (DHE), preferably in intranasal formulation 2, 3
3. Third alternative option: Lasmiditan for patients who don't tolerate or have inadequate response to all other treatments 1

Important Considerations and Precautions

• Avoid opioids and butalbital-containing medications for migraine treatment as they can lead to dependency, rebound headaches, and eventual loss of efficacy 1, 2
• Be aware of medication overuse headache, which can occur with frequent use of acute medications (≥15 days per month with NSAIDs; ≥10 days per month with triptans) 1
• DHE is contraindicated in patients with uncontrolled hypertension, coronary artery disease, or peripheral vascular disease 1, 3
• When using DHE, the recommended dosage is 1 spray in each nostril followed in 15 minutes by an additional spray in each nostril, for a total of 4 sprays 3

Preventive Therapy Considerations

• If episodic migraine occurs frequently or treatment doesn't provide adequate response, preventive medications should be considered 1
• Commonly accepted indications for migraine prevention include two or more migraine attacks per month with attacks producing disability for three or more days per month 1

Lifestyle Modifications

• Emphasize lifestyle modifications including staying well hydrated, maintaining regular meals, securing sufficient and consistent sleep, engaging in regular physical activity, managing stress, and identifying triggers 1
• Tracking progress with a daily headache diary can be helpful in assessing treatment response and identifying triggers 1

Special Situations

• For patients with severe nausea or vomiting, consider using a nonoral formulation (such as intranasal DHE) and an antiemetic 1, 3
• For women of childbearing potential, discuss the adverse effects of pharmacologic treatments during pregnancy and lactation 1, 4