What are the next steps for treating headaches that do not respond to meloxicam (Nonsteroidal Anti-Inflammatory Drug, NSAID)?

Next Steps for Headaches Not Responding to Meloxicam

When headaches fail to respond to meloxicam (an NSAID), the next step is to escalate to migraine-specific agents, specifically triptans or dihydroergotamine (DHE), as these represent evidence-based second-line therapy for NSAID-refractory headaches. 1, 2

Immediate Treatment Algorithm

Step 1: Switch to Migraine-Specific Agents

• Oral triptans are the preferred next step, with strong evidence supporting naratriptan, rizatriptan, sumatriptan, and zolmitriptan 1, 2
• These agents eliminate pain in 20-30% of patients by 2 hours 3
• Subcutaneous sumatriptan offers the most rapid onset and is particularly useful when quick relief is needed 4
• Intranasal DHE represents an alternative with good efficacy and safety data 1, 2

Step 2: Consider Route of Administration

• If nausea or vomiting is present early in the attack, use non-oral routes (subcutaneous, intranasal, or rectal) 1, 4
• Add an antiemetic such as metoclopramide (10 mg IV) or prochlorperazine (10 mg IV), which provide synergistic analgesia beyond just treating nausea 2, 4

Step 3: Alternative Second-Line Options

• For patients with cardiovascular risk factors or contraindications to triptans (uncontrolled hypertension, coronary artery disease, basilar or hemiplegic migraine), consider: 1, 4, 3
  • Gepants (rimegepant or ubrogepant) - eliminate headache in 20% of patients at 2 hours with minimal cardiovascular risk 3
  • Lasmiditan (5-HT1F agonist) - safe in patients with cardiovascular risk factors 3
  • Intranasal DHE - good efficacy without the cardiovascular concerns of triptans 1, 2

Critical Medication Overuse Warning

Limit acute headache treatments to no more than twice weekly to prevent medication-overuse headache, which causes increasing headache frequency and can progress to daily headaches 1, 2, 4

• If the patient is already using meloxicam or other acute medications more than 2 times per week, initiate preventive therapy immediately rather than simply switching acute medications 1, 5
• Medication-overuse headache affects 0.5-2.0% of the population and requires a different treatment approach including patient education, prophylaxis, and potentially a medication pause 5

When to Consider Preventive Therapy

Evaluate for preventive therapy if any of the following apply: 1

• Two or more attacks per month producing disability lasting 3+ days
• Contraindication to or failure of acute treatments
• Use of abortive medication more than twice per week
• Presence of hemiplegic migraine, prolonged aura, or migrainous infarction

Rescue Medication Strategy

• For severe attacks failing first and second-line treatments, consider a rescue medication (opioid or butalbital compound) that can be used at home 1
• However, opioids should only be used when other medications cannot be used, sedation is acceptable, and abuse risk has been addressed 1, 2
• Butorphanol nasal spray has better evidence than other opioids for headache treatment 1, 2

Important Contraindications to Avoid

• Never use triptans in patients with: uncontrolled hypertension, basilar or hemiplegic migraine, coronary artery disease, or concurrent use of ergotamines 4, 3
• Avoid establishing patterns of frequent opioid use as this leads to dependency, rebound headaches, and loss of efficacy 2, 4
• Acetaminophen alone is ineffective for migraine and should not be used as monotherapy 1, 4