What is the best first-line therapy for a patient with left-sided, throbbing headaches associated with nausea, lasting 48 hours per week?

First-Line Therapy for Migraine Without Aura

For this patient with left-sided, throbbing headaches with nausea lasting 48 hours per week, start with an oral triptan (sumatriptan 50-100 mg or rizatriptan) combined with an NSAID (naproxen sodium 500 mg or ibuprofen 400-800 mg) at headache onset, and immediately initiate preventive therapy since the patient requires acute treatment more than twice weekly. 1

Why Combination Therapy is First-Line

• The combination of triptan plus NSAID is superior to either agent alone, with 130 more patients per 1000 achieving sustained pain relief at 48 hours compared to monotherapy 1
• This patient has moderate-to-severe migraine (throbbing headache with nausea lasting 48 hours), which warrants triptan therapy rather than starting with NSAIDs alone 2, 1
• Sumatriptan 50-100 mg achieves headache response (reduction to mild or no pain) in 50-62% of patients at 2 hours and 68-79% at 4 hours, compared to 17-38% with placebo 3

Critical Frequency Problem Requiring Immediate Preventive Therapy

This patient is already at high risk for medication-overuse headache because they have headaches lasting 48 hours per week, which means they will need acute treatment more than twice weekly. 1

• Acute migraine medications must be limited to no more than 2 days per week to prevent medication-overuse headache, which paradoxically increases headache frequency and can lead to daily headaches 2, 1
• Preventive therapy is indicated immediately for patients requiring acute treatment more than twice weekly, with the goal of reducing attack frequency by ≥50% 1
• First-line preventive options include propranolol 80-240 mg/day, topiramate, or amitriptyline 30-150 mg/day 1

Specific Acute Treatment Algorithm

For Each Attack:

1. Take medication early when headache is still mild for maximum effectiveness 2, 4
2. Sumatriptan 50-100 mg PLUS naproxen sodium 500 mg (or ibuprofen 400-800 mg) at onset 1, 5
3. Add metoclopramide 10 mg for nausea, which also provides direct analgesic benefit through central dopamine receptor antagonism 1, 6
4. If inadequate response after 2 hours, can repeat triptan dose once (maximum 2 doses in 24 hours) 3

Alternative Routes if Nausea Worsens:

• Subcutaneous sumatriptan 6 mg provides the highest efficacy (70-80% response at 1 hour) with onset within 15 minutes for patients with severe nausea or rapid progression to peak intensity 2, 1, 4
• Intranasal sumatriptan 5-20 mg is another non-oral option 1

Common Pitfalls to Avoid

• Do not allow this patient to use acute medications more than 2 days per week—this creates a vicious cycle of medication-overuse headache 1
• Do not delay preventive therapy—waiting will only worsen the pattern and potentially cause transformation to chronic daily headache 1
• Do not take triptans during aura phase—wait until headache begins 2
• Do not use triptans if patient has uncontrolled hypertension, ischemic heart disease, or significant cardiovascular disease 6, 5

Why Not Start with NSAIDs Alone?

• NSAIDs alone are first-line only for mild-to-moderate migraine 2, 1
• This patient has moderate-to-severe features (throbbing headache with nausea lasting 48 hours), which requires triptan therapy 1, 5
• Starting with inadequate therapy wastes time and increases suffering, when combination therapy has proven superior efficacy 1

Monitoring and Follow-Up

• Assess preventive therapy efficacy after 2-3 months for oral agents 1
• If triptan fails after adequate trial (no response in 3 consecutive attacks), try a different triptan before declaring class failure 2
• Track headache frequency to ensure acute medication use stays ≤2 days per week 1