Treatment for Complicated Migraine
For complicated migraine (migraine with aura or neurological symptoms), triptans are the first-line treatment for moderate to severe attacks, with NSAIDs reserved for mild to moderate attacks, and critical attention must be paid to ruling out contraindications specific to complicated migraine subtypes. 1, 2
Understanding "Complicated Migraine"
The term "complicated migraine" typically refers to migraine with aura, hemiplegic migraine, basilar-type migraine, or migraine with prolonged neurological symptoms. These patients require special consideration because:
- Triptans are absolutely contraindicated in basilar-type and hemiplegic migraine due to risk of vasoconstriction in already compromised vascular territories 1, 3
- Patients with these uncommon migraine conditions are candidates for preventive therapy regardless of attack frequency 4
First-Line Acute Treatment Algorithm
For Mild to Moderate Attacks (Without Contraindications)
Start with NSAIDs as first-line therapy:
- Ibuprofen 400-800 mg at onset 1, 2
- Naproxen sodium 500-825 mg at onset 1, 2
- Aspirin 900-1000 mg at onset 2
Critical timing: Take medication early when pain is still mild for maximum effectiveness 1, 2
For Moderate to Severe Attacks (Without Contraindications)
Triptans are first-line, but avoid in basilar and hemiplegic migraine:
- Sumatriptan 50-100 mg orally (most studied, NNT 4.7 for pain-free at 2 hours with 100 mg dose) 1, 5
- Rizatriptan, naratriptan, or zolmitriptan are alternatives 1
- Combination therapy is superior: Sumatriptan PLUS naproxen sodium provides better outcomes than either alone, with 130 more patients per 1000 achieving sustained pain relief at 48 hours 1
Route selection based on severity:
- Subcutaneous sumatriptan 6 mg provides fastest relief (70-82% response within 15 minutes, 59% pain-free by 2 hours) for severe attacks or when nausea/vomiting is prominent 1, 6, 7
- Intranasal formulations (sumatriptan 5-20 mg) for patients with significant nausea who prefer to avoid injections 1, 2
When Triptans Are Contraindicated
For patients with basilar-type or hemiplegic migraine, or cardiovascular contraindications:
- First choice: NSAIDs (ketorolac 30 mg IV for severe attacks) 1
- Second choice: Antiemetics with analgesic properties (metoclopramide 10 mg IV or prochlorperazine 10 mg IV) provide direct pain relief beyond treating nausea 1, 2
- Third choice: Dihydroergotamine (DHE) 0.5-1 mg IM/IV or intranasal, though also contraindicated in basilar and hemiplegic migraine 1, 2
Critical Frequency Limitation
Limit ALL acute medications to no more than 2 days per week to prevent medication-overuse headache, which paradoxically increases headache frequency and can lead to daily headaches 1, 2, 4
Preventive Therapy Indication
Patients with complicated migraine should be immediately evaluated for preventive therapy because:
- Uncommon migraine conditions (hemiplegic, prolonged aura, migrainous infarction) are automatic indications for prevention regardless of frequency 4
- First-line preventive options: Propranolol 80-240 mg/day, topiramate 100 mg/day (50 mg twice daily), or candesartan 4
- Allow 2-3 months for adequate trial before determining efficacy 4
Common Pitfalls to Avoid
- Never give triptans during the aura phase - wait until headache begins, as triptans during aura may be ineffective and potentially harmful 2
- Never use triptans in basilar or hemiplegic migraine - risk of stroke from vasoconstriction in compromised territories 1, 3
- Avoid establishing frequent acute medication use patterns - this creates medication-overuse headache and requires transition to preventive therapy 1, 4
- Do not delay preventive therapy in patients with complicated migraine, as these conditions warrant prevention regardless of attack frequency 4
Optimal IV "Cocktail" for Severe Attacks (When Triptans Contraindicated)
Metoclopramide 10 mg IV PLUS ketorolac 30 mg IV provides rapid relief with minimal rebound risk and addresses both pain and nausea through complementary mechanisms 1