What is the best course of treatment for a 35-year-old female with a history of migraines, asthma, and obesity, presenting with a non-traumatic throbbing headache, nausea, and presyncope?

Acute Treatment of Migraine with Severe Nausea and Presyncope

Start immediate treatment with a non-oral triptan (subcutaneous or intranasal sumatriptan) combined with an antiemetic, as the American College of Physicians specifically recommends non-oral triptans with antiemetics for patients presenting with severe nausea or vomiting. 1

Immediate Management Approach

First-Line Acute Treatment

• Administer subcutaneous sumatriptan 6 mg or intranasal sumatriptan as the preferred route given the severe nausea, which impairs oral medication absorption and efficacy 1
• Add an antiemetic immediately (metoclopramide 10 mg IV/IM or prochlorperazine 10 mg IV/IM) to address the nausea and enhance triptan efficacy 1
• Begin treatment as soon as possible after symptom onset to maximize efficacy 1

Critical Safety Considerations for This Patient

• Evaluate for cardiovascular risk factors before administering triptans, as this patient has obesity (BMI 65), which is associated with increased cardiovascular risk 2, 3
• Triptans are contraindicated in uncontrolled hypertension and coronary artery disease; check blood pressure and assess for cardiac symptoms before administration 2
• The presyncope warrants brief cardiovascular assessment to rule out cardiac causes, though it is commonly seen with migraine-related autonomic dysfunction 4
• Monitor for serotonin syndrome if the patient takes SSRIs or SNRIs, though this is rare 2

Asthma Considerations

• Avoid NSAIDs if the patient has aspirin-sensitive asthma, as NSAIDs can trigger bronchospasm in susceptible individuals 1
• If no aspirin sensitivity exists, NSAIDs can be added to triptan therapy once nausea improves 1

Preventive Therapy - Essential Given Presentation Timing

This patient requires immediate initiation of preventive therapy, as the American College of Physicians states that frequent episodic migraines warrant preventive medications 1

First-Line Preventive Options

• Topiramate 50-100 mg/day is the evidence-based first choice for chronic migraine prevention and has the added benefit of potential weight loss in this obese patient 1, 5
• Beta-blockers (propranolol 80-240 mg/day) are an alternative first-line option that also treats potential cardiovascular risk 5
• Amitriptyline 30-150 mg/day can be considered if comorbid depression or insomnia is present 5

Obesity-Specific Considerations

• Weight loss should be strongly emphasized, as obesity is a recognized risk factor for transformation from episodic to chronic migraine 1, 6
• Inflammatory mediators increased in obesity (interleukins, CGRP) may worsen migraine frequency and severity 6
• Topiramate offers dual benefit as it may facilitate weight loss while preventing migraines 1, 5

Medication Overuse Headache Prevention

Counsel the patient immediately about medication overuse headache, which occurs with triptan use ≥10 days per month or NSAID use ≥15 days per month 1

• This patient's daily or near-daily headaches raise concern for potential medication overuse if she has been self-treating frequently 1
• Abrupt withdrawal of overused medications is preferred (except opioids), followed by initiation of preventive therapy 1
• Never prescribe opioids or butalbital for migraine treatment, as explicitly contraindicated by the American College of Physicians 1

Follow-Up and Monitoring

• Schedule follow-up in 4 weeks to assess treatment response and adjust preventive therapy as needed 5
• Implement a headache diary to track frequency, severity, triggers, and medication use 1, 5
• If preventive therapy fails after 2-3 medication trials, consider referral to neurology for CGRP monoclonal antibodies or onabotulinumtoxinA 1, 5

Lifestyle Modifications - Non-Negotiable

Implement these evidence-based lifestyle changes immediately, as recommended by the American College of Physicians 1:

• Maintain regular sleep schedule (7-9 hours nightly)
• Eat consistent meals without skipping
• Stay well-hydrated throughout the day
• Engage in regular moderate-to-intense aerobic exercise (as tolerated with obesity)
• Practice stress management with relaxation techniques or mindfulness
• Pursue structured weight loss program given BMI 65 and its role in migraine chronification 1, 6

Red Flags Requiring Emergency Evaluation

If any of the following develop, immediate neuroimaging and emergency evaluation are required 1:

• Sudden onset "thunderclap" headache
• Headache with fever, stiff neck, or altered mental status
• New neurologic deficits beyond typical aura
• Headache worsening with Valsalva maneuver
• Progressive worsening over days to weeks
• First severe headache in a patient over age 50