What is the plan of care for a patient presenting with acute migraines?

Plan of Care for Acute Migraine Treatment

For patients presenting with acute migraines, the recommended first-line treatment is NSAIDs (acetylsalicylic acid, ibuprofen, or diclofenac potassium), followed by triptans as second-line therapy if NSAIDs are ineffective, with treatment administered early in the headache phase for optimal effectiveness. 1

Initial Assessment

• Rule out secondary headaches by checking for red flags such as thunderclap headache, atypical aura, head trauma, progressive headache, or headache onset after age 50 1
• Assess migraine severity (mild, moderate, or severe) to guide treatment selection 2
• Evaluate for nausea/vomiting which may require antiemetics and alternative routes of administration 1

Stepped Care Approach for Acute Treatment

First-Line Treatment (Mild to Moderate Migraine)

• NSAIDs with proven efficacy:
  • Ibuprofen (400mg preferred over 200mg) 1, 3
  • Diclofenac potassium 1
  • Acetylsalicylic acid (aspirin) 1
  • Naproxen sodium 1
• Acetaminophen is an option only for patients intolerant to NSAIDs 1
• Take medication early in the headache phase for maximum effectiveness 1

Second-Line Treatment (Moderate to Severe Migraine or NSAID Failure)

• Triptans (sumatriptan, rizatriptan, eletriptan, zolmitriptan, almotriptan, frovatriptan, or naratriptan) 1
• Most effective when taken early while pain is still mild 1
• If one triptan fails, try another as individual response varies 1
• For rapid onset or severe vomiting, consider subcutaneous sumatriptan 1
• Clinical trials show triptans provide headache relief in 50-62% of patients at 2 hours compared to 17-27% with placebo 4

Third-Line Treatment (Triptan Failure or Contraindication)

• CGRP antagonists (gepants): rimegepant, ubrogepant, or zavegepant 1
• Ditan: lasmiditan (note: causes driving impairment for at least 8 hours after intake) 1
• For relapse after initial treatment success, consider combining triptan with fast-acting NSAID 1

Adjunct Medications

• For nausea/vomiting: prokinetic antiemetics (domperidone or metoclopramide) 1
• Consider non-oral routes of administration (subcutaneous, intranasal) for patients with severe nausea/vomiting 1

Medications to Avoid

• Opioids and butalbital-containing medications (risk of dependency and questionable efficacy) 1, 2
• Oral ergot alkaloids (poor efficacy and potential toxicity) 1

Patient Education

• Explain migraine as a neurological disease and principles of management 1
• Advise on early treatment for best results 1
• Warn about medication overuse headache risk (≥15 days/month with NSAIDs; ≥10 days/month with triptans) 1
• Discuss lifestyle modifications that may help (sleep quality, physical fitness, stress management) 1

Prevention Considerations

• Consider preventive therapy if:
  • Migraines significantly impact quality of life despite optimized acute treatment 1
  • Patient experiences ≥2 migraine days per month with significant disability 1, 5
  • Acute medications are contraindicated, ineffective, or causing side effects 1, 5
  • Patient is overusing acute medications 1
• First-line preventive options include propranolol, timolol, amitriptyline, and divalproex sodium 1, 5
• Preventive treatments typically require 2-3 months to demonstrate efficacy 1

Follow-up Plan

• Re-evaluate treatment effectiveness and adjust as needed 1
• Monitor for medication overuse headache 1
• Consider preventive therapy if attacks remain frequent or severe despite optimal acute treatment 1, 5