What is the best management approach for a 25-year-old patient experiencing migraines?

Management of Migraine in a 25-Year-Old Patient

For acute migraine attacks in a 25-year-old, start with NSAIDs (ibuprofen, aspirin, or diclofenac) plus an antiemetic if needed, and escalate to triptans if three consecutive attacks fail to respond adequately to NSAIDs. 1

Acute Treatment Algorithm

First-Line: NSAIDs

• Begin with over-the-counter NSAIDs including ibuprofen, aspirin (acetylsalicylic acid), or diclofenac potassium 1
• These have the strongest evidence for efficacy and should be tried first in most patients 1
• Paracetamol (acetaminophen) alone is ineffective and should only be used if NSAIDs are contraindicated 1
• Add an antiemetic if nausea or vomiting is present 1

Second-Line: Triptans

• Switch to triptans after three consecutive attacks without adequate response to NSAIDs 1
• All triptans have well-documented effectiveness, with good evidence for sumatriptan (oral and subcutaneous), naratriptan, rizatriptan, and zolmitriptan 1
• Triptans are most effective when taken early during an attack while headache is still mild 1
• If one triptan fails, try different triptans as individual response varies 1
• Sumatriptan 50-100 mg orally achieves headache response (reduction to mild or no pain) in 50-62% of patients at 2 hours and 68-79% at 4 hours 2
• For rapid-onset severe attacks or when vomiting prevents oral medication, use subcutaneous sumatriptan 1

Critical Pitfall: Triptans should not be used in patients with uncontrolled hypertension, coronary artery disease, hemiplegic or basilar migraine, or cardiovascular risk factors without proper evaluation 1, 2

Preventive Treatment Indications

Consider preventive therapy if the patient experiences migraine-related disability on ≥2 days per month despite optimized acute treatment 1

First-Line Preventive Medications

Choose from beta-blockers, topiramate, or candesartan 1:

• Beta-blockers: Propranolol 80-160 mg daily (long-acting), metoprolol 50-100 mg twice daily or 200 mg modified-release once daily, atenolol 25-100 mg twice daily, or bisoprolol 5-10 mg once daily 1

  • Contraindicated in asthma, cardiac failure, Raynaud disease, atrioventricular block, and depression 1

• Topiramate: 50-100 mg oral daily 1

  • Has proven efficacy in randomized controlled trials for both episodic and chronic migraine 1
  • Absolutely contraindicated in pregnancy and lactation 1
  • Common adverse effects include cognitive inefficiency, paresthesia, fatigue, and weight loss 1

• Candesartan: 16-32 mg oral daily 1

Second-Line Preventive Medications

If first-line agents fail or are contraindicated 1:

• Amitriptyline: 10-100 mg oral at night 1
• Flunarizine: 5-10 mg oral once daily (contraindicated in depression and Parkinsonism) 1
• Sodium valproate: 600-1,500 mg oral daily in men only 1
  • Absolutely contraindicated in women of childbearing potential due to teratogenicity 1

Third-Line Preventive Medications

For patients who fail multiple first- and second-line agents 1:

• CGRP monoclonal antibodies: Erenumab (70-140 mg subcutaneous monthly), fremanezumab (225 mg subcutaneous monthly or 675 mg quarterly), galcanezumab, or eptinezumab (100-300 mg intravenous quarterly) 1
• OnabotulinumtoxinA: 155-195 units to 31-39 sites every 12 weeks 1
  • This is the only FDA-approved therapy specifically for chronic migraine prophylaxis 1

Special Considerations for Young Women

If the patient is female with menstrual-related migraines:

• Consider perimenstrual prophylaxis with a long-acting NSAID (naproxen) or triptan (frovatriptan or naratriptan) for 5 days, beginning 2 days before expected menstruation 1
• Combined hormonal contraceptives are absolutely contraindicated if migraine with aura is present due to increased stroke risk 1

Medication Overuse Prevention

Critical Warning: Limit acute treatment use to no more than twice weekly (or <10 days/month for triptans, <15 days/month for simple analgesics) to prevent medication overuse headache 1

• Medication overuse headache presents as daily or near-daily headaches and requires withdrawal of overused medications 2
• If medication overuse is suspected or at risk, initiate preventive therapy immediately 1

Monitoring and Follow-Up

• Evaluate treatment response 2-3 months after initiation or change in treatment 1
• Use a headache diary to track attack frequency, severity, disability, and medication use 1
• Monitor for adverse effects and adherence 1
• Key outcome measures include headache days per month, pain intensity, and migraine-related disability 1

Non-Pharmacological Adjuncts

Consider as additions to medication or when medications are contraindicated 1:

• Neuromodulatory devices (evidence supports use) 1
• Biobehavioral therapy 1
• Acupuncture (though not superior to sham acupuncture) 1