What is the recommended treatment for a patient presenting with acute migraine, considering their past medical history and potential for frequent or severe migraines?

Acute Migraine Treatment

For acute migraine, start with NSAIDs (ibuprofen 400-800 mg, naproxen 500-825 mg, or aspirin 1000 mg) for mild-to-moderate attacks, and immediately escalate to a triptan (sumatriptan 50-100 mg, rizatriptan 10 mg, or eletriptan 40 mg) for moderate-to-severe attacks or when NSAIDs fail—the combination of triptan plus NSAID taken simultaneously provides superior efficacy and represents the strongest current recommendation. 1, 2

Treatment Algorithm Based on Attack Severity

Mild-to-Moderate Attacks

• First-line: NSAIDs with proven efficacy include ibuprofen 400-800 mg, naproxen sodium 500-825 mg, aspirin 1000 mg, or diclofenac potassium 50-100 mg 1, 2, 3
• The combination of acetaminophen 1000 mg plus aspirin 1000 mg plus caffeine 130 mg is also effective as first-line therapy 1, 2
• Acetaminophen 1000 mg alone has inferior efficacy (NNT of 12 for pain-free response at 2 hours) and should only be used when NSAIDs are contraindicated 1, 4
• Take medication early in the attack while pain is still mild to maximize effectiveness 1, 2

Moderate-to-Severe Attacks

• First-line: Triptans are recommended, with oral options including sumatriptan 50-100 mg, rizatriptan 10 mg, eletriptan 40 mg, zolmitriptan 2.5-5 mg, almotriptan 12.5 mg, naratriptan 2.5 mg, or frovatriptan 2.5 mg 1, 2, 3
• Combination therapy (triptan + NSAID taken simultaneously) is superior to either agent alone, with 130 more patients per 1000 achieving sustained pain relief at 48 hours compared to monotherapy 1
• Sumatriptan 50-100 mg demonstrates 52-62% headache response at 2 hours and 65-79% at 4 hours, compared to 17-27% with placebo 5

Attacks with Significant Nausea/Vomiting

• Select non-oral routes: subcutaneous sumatriptan 6 mg (most effective, 59% pain-free at 2 hours, onset within 15 minutes) or intranasal sumatriptan 5-20 mg 1, 2, 3
• Add antiemetic: metoclopramide 10 mg IV/oral or prochlorperazine 10 mg IV/oral provides both antiemetic effects and synergistic analgesia through central dopamine receptor antagonism 1, 2
• Intranasal dihydroergotamine (DHE) is an alternative with good evidence for efficacy 1, 3

Rescue Treatment for Failed Initial Therapy

When NSAIDs Fail (Within 2 Hours)

• Escalate to a triptan immediately 2, 6
• Consider the combination of triptan plus NSAID if not already used 1

When Triptans Fail

• Try a different triptan first—failure of one triptan does not predict failure of others 1, 2
• If oral triptan fails, consider subcutaneous sumatriptan 6 mg for rapid onset 1, 2
• Third-line options include ditans (lasmiditan) or gepants (ubrogepant, rimegepant, zavegepant) when all triptans fail or are contraindicated 1, 2

Urgent Care/IV Treatment for Refractory Attacks

• First-line IV combination: metoclopramide 10 mg IV plus ketorolac 30 mg IV provides rapid relief with minimal rebound risk 1
• Alternative: prochlorperazine 10 mg IV (comparable efficacy to metoclopramide, 21% adverse event rate vs 50% with chlorpromazine) 1
• DHE IV/IM is effective for refractory attacks 1, 3
• Avoid opioids (hydromorphone, oxycodone) except when all other options are contraindicated, sedation is acceptable, and abuse risk has been addressed 1

Critical Medication Frequency Limits

Limit ALL acute migraine medications to no more than 2 days per week (not 2 attacks per week) to prevent medication-overuse headache (MOH), which paradoxically increases headache frequency and can lead to daily headaches. 1, 2

• NSAIDs trigger MOH at ≥15 days/month 1
• Triptans trigger MOH at ≥10 days/month 1
• If using acute medications more than twice weekly, initiate preventive therapy immediately 1

Contraindications Requiring Alternative Approach

Triptans are Contraindicated in:

• Ischemic heart disease, previous myocardial infarction, coronary artery vasospasm (Prinzmetal's angina) 5
• Uncontrolled hypertension 5
• History of stroke or transient ischemic attack 1, 5
• Wolff-Parkinson-White syndrome or other cardiac accessory conduction pathway disorders 5
• Peripheral vascular disease, Raynaud's syndrome 5

For Patients with Cardiovascular Contraindications:

• Use NSAIDs as primary therapy 1
• Add antiemetics (metoclopramide or prochlorperazine) for synergistic analgesia 1
• Consider DHE nasal spray (though also has vascular contraindications) 1
• Gepants (ubrogepant, rimegepant) are non-vasoconstricting alternatives 1

Special Populations

Pregnancy

• Safest option: acetaminophen 1000 mg 7
• Acetaminophen with codeine is also an option for severe attacks 7
• Sumatriptan may be considered for selected patients after risk-benefit discussion 7

Lactation

• Sumatriptan is compatible with breast-feeding 7

Patients with Frequent Migraines

• If experiencing ≥2 attacks per month producing disability for ≥3 days, or using acute medications >2 days/week, preventive therapy is indicated 1
• Preventive options include propranolol 80-240 mg/day, topiramate, divalproex sodium, amitriptyline 30-150 mg/day, or CGRP monoclonal antibodies 1

Common Pitfalls to Avoid

• Do NOT use triptans during the aura phase—wait until headache phase begins 2
• Do NOT delay treatment—early administration during mild pain improves efficacy 1, 2
• Do NOT establish patterns of opioid use—this leads to dependency, MOH, and loss of efficacy 1
• Do NOT use acetaminophen alone as first-line—it has inferior efficacy compared to NSAIDs 1, 4
• Do NOT assume all triptans are equivalent for an individual patient—trial different triptans if one fails 1, 2
• Do NOT allow patients to increase acute medication frequency in response to treatment failure—instead transition to preventive therapy 1