What is the recommended treatment for a patient experiencing migraines, considering their medical history and potential risk factors such as cardiovascular disease?

Acute Migraine Treatment Protocol

For acute migraine treatment, start with combination therapy of a triptan plus NSAID (sumatriptan 50-100 mg + naproxen 500 mg) for moderate to severe attacks, or NSAID monotherapy (ibuprofen 400-800 mg or naproxen 500-825 mg) for mild to moderate attacks, with the critical caveat that all acute medications must be limited to no more than 2 days per week to prevent medication-overuse headache. 1

First-Line Treatment Algorithm

For Mild to Moderate Migraine

• Initiate with NSAIDs alone: ibuprofen 400-800 mg, naproxen sodium 500-825 mg, or aspirin 1000 mg at the earliest sign of headache while pain is still mild 1, 2
• Add metoclopramide 10 mg orally 20-30 minutes before the NSAID to enhance absorption and provide synergistic analgesia, even if nausea is not present 1, 2

For Moderate to Severe Migraine

• Use combination therapy immediately: sumatriptan 50-100 mg PLUS naproxen sodium 500 mg, which provides 130 more patients per 1000 achieving sustained pain relief at 48 hours compared to either agent alone 1
• This combination represents the strongest recommendation from current guidelines and is superior to monotherapy with either agent 1

For Severe or Refractory Migraine (Emergency Setting)

• IV cocktail: ketorolac 30 mg IV + metoclopramide 10 mg IV (or prochlorperazine 10 mg IV) + IV fluids for hydration 1
• If inadequate response after 30-60 minutes, add dihydroergotamine (DHE) 1 mg IV or sumatriptan 6 mg subcutaneously 1
• Subcutaneous sumatriptan 6 mg provides the highest efficacy with 70-80% relief within 15 minutes and 59% complete pain relief by 2 hours 1, 3

Critical Cardiovascular Contraindications

Triptans and ergot derivatives are absolutely contraindicated in patients with: 1, 3, 4

• Ischemic heart disease or previous myocardial infarction
• Coronary artery vasospasm or Prinzmetal's angina
• Uncontrolled hypertension
• Peripheral vascular disease
• History of stroke or transient ischemic attack
• Hemiplegic or basilar migraine
• Wolff-Parkinson-White syndrome or other cardiac accessory conduction pathway disorders

For patients with cardiovascular risk factors (hypertension, hyperlipidemia, diabetes, smoking, obesity, family history of heart disease), perform cardiac evaluation before prescribing triptans 1, 3

Alternative Approach for Cardiovascular Contraindications

• Use ketorolac 30 mg IV + metoclopramide 10 mg IV without triptans 1
• Consider newer CGRP antagonists (rimegepant, ubrogepant, zavegepant) which lack cardiovascular contraindications 2

Medication-Overuse Headache Prevention

The single most important pitfall to avoid is medication-overuse headache (MOH): 1, 2

• Strictly limit ALL acute migraine medications to no more than 2 days per week 1
• Triptans trigger MOH at ≥10 days per month of use 1
• NSAIDs trigger MOH at ≥15 days per month of use 1
• If patients require acute treatment more than twice weekly, immediately initiate preventive therapy rather than increasing frequency of acute medications 1

When to Escalate to Preventive Therapy

Initiate preventive therapy immediately if: 5

• Two or more migraine attacks per month producing disability lasting 3+ days 5
• Using acute medications more than twice per week 5
• Contraindications to acute treatments exist 5
• Acute treatments have failed after adequate trials 5

First-Line Preventive Options

• Beta-blockers: propranolol 80-240 mg/day or timolol 20-30 mg/day 5
• Topiramate: 100 mg/day (typically 50 mg twice daily) 5
• Candesartan: particularly useful with comorbid hypertension 5

Allow 2-3 months for adequate trial of oral preventive medications before determining efficacy 5

Medications to Avoid

Strongly avoid opioids and butalbital-containing compounds: 1, 2

• Lead to dependency and medication-overuse headache 1
• Cause eventual loss of efficacy 1
• Should only be reserved for when all other options are contraindicated and abuse risk has been addressed 2

Administration Timing

Take medication at the earliest sign of headache while pain is still mild for maximum effectiveness, as triptans and NSAIDs work best when administered early in the attack 1, 2

Headache Recurrence Management

Approximately 40% of patients experience headache recurrence within 24 hours after initial sumatriptan response 6, 7

• A second dose of the same medication effectively treats recurrence 1, 6
• Maximum of two triptan doses in 24 hours 1
• Do not exceed the 2-days-per-week frequency limit even with recurrent headaches 1