What is the recommended treatment for a patient with migraines, considering potential cardiovascular disease or stroke history?

Migraine Treatment

For patients with cardiovascular disease or stroke history, NSAIDs (ibuprofen 400-800 mg, naproxen 500-825 mg, or aspirin 1000 mg) are the recommended first-line treatment for mild-to-moderate migraine attacks, while triptans are contraindicated due to their vasoconstrictive properties and risk of coronary artery vasospasm. 1, 2

First-Line Treatment Algorithm

For Patients WITHOUT Cardiovascular Disease or Stroke History

Mild-to-Moderate Attacks:

• Start with NSAIDs: ibuprofen 400-800 mg, naproxen sodium 500-825 mg, or aspirin 1000 mg 1, 3
• Add metoclopramide 10 mg if nausea is present for synergistic analgesia 1
• Administer early when pain is still mild for maximum effectiveness 3

Moderate-to-Severe Attacks:

• Use combination therapy: sumatriptan 50-100 mg PLUS naproxen sodium 500 mg, which is superior to either agent alone 1, 3
• This combination provides 130 more patients per 1000 achieving sustained pain relief at 48 hours compared to monotherapy 1
• Add antiemetic (metoclopramide 10 mg or prochlorperazine 10 mg IV) if nausea is present 1

For Patients WITH Cardiovascular Disease or Stroke History

Critical Contraindications:

• Triptans are absolutely contraindicated in patients with ischemic heart disease, previous myocardial infarction, Prinzmetal's angina, uncontrolled hypertension, history of stroke or TIA, or multiple cardiovascular risk factors 2, 4, 5
• Ergots (including dihydroergotamine) are contraindicated after TIA/ischemic stroke 5
• NSAIDs are contraindicated in patients with cerebral bleeding 5

Recommended Treatment Approach:

• Use NSAIDs (ibuprofen, naproxen, or aspirin) as first-line for mild-to-moderate attacks if no history of cerebral bleeding 1, 5
• Add antiemetics for synergistic analgesia: metoclopramide 10 mg IV or prochlorperazine 10 mg IV 1
• For severe attacks requiring IV treatment: metoclopramide 10 mg IV plus ketorolac 30 mg IV (if no renal impairment or GI bleeding history) 1

Intravenous Treatment for Severe Attacks

Optimal IV Cocktail:

• Metoclopramide 10 mg IV plus ketorolac 30 mg IV provides rapid pain relief with minimal rebound headache risk 1
• Metoclopramide provides direct analgesic effects through central dopamine receptor antagonism, independent of its antiemetic properties 1
• Ketorolac has rapid onset with approximately 6 hours duration 1

Alternative IV Options:

• Prochlorperazine 10 mg IV is comparable to metoclopramide in efficacy 1
• Avoid opioids as they lead to dependency, rebound headaches, and loss of efficacy 1

Critical Frequency Limitation

To Prevent Medication-Overuse Headache:

• Strictly limit ALL acute migraine medications to no more than 2 days per week 1, 3
• Using acute medications more than twice weekly leads to medication-overuse headache, causing daily headaches and loss of treatment efficacy 1, 3
• If patients require acute treatment more than twice weekly, immediately initiate preventive therapy 1, 6

Preventive Therapy Indications

When to Start Prevention:

• Two or more migraine attacks per month with disability lasting 3+ days 6
• Use of abortive medication more than twice per week 6
• Contraindication to or failure of acute treatments 6
• Uncommon migraine conditions (hemiplegic migraine, prolonged aura, migrainous infarction) 6

First-Line Preventive Medications:

• Propranolol 80-240 mg/day or timolol 20-30 mg/day (strong evidence for efficacy) 6
• Topiramate 100 mg/day (typically 50 mg twice daily) 6
• Candesartan (particularly useful with comorbid hypertension) 6

For Patients with Cardiovascular Disease:

• Beta-blockers (propranolol, timolol, metoprolol, atenolol, bisoprolol) are appropriate first-line preventive options 6
• Candesartan is particularly useful with comorbid hypertension 6
• Avoid valproate in women of childbearing potential due to teratogenic effects 6

Common Pitfalls to Avoid

• Failing to treat early: Triptans and NSAIDs are most effective when taken early while pain is still mild 3
• Using triptans in cardiovascular patients: This can cause coronary artery vasospasm, myocardial ischemia, arrhythmias, and cerebrovascular events 2, 7
• Allowing frequent acute medication use: This creates medication-overuse headache; transition to preventive therapy instead 1, 3
• Inadequate preventive trial duration: Allow 2-3 months before determining efficacy of oral preventive medications 6
• Not recognizing medication-overuse headache: Frequent use (≥10 days/month for triptans, ≥15 days/month for NSAIDs) causes MOH 1, 2

Special Cardiovascular Considerations

Migraine with Aura and CVD Risk:

• Migraine with aura is associated with increased risk of ischemic stroke, atrial fibrillation, myocardial infarction, and cardiovascular death 7
• This further emphasizes the importance of avoiding vasoconstrictive medications (triptans, ergots) in these patients 7, 5

Cardiovascular Evaluation Before Triptan Use:

• For triptan-naive patients with multiple cardiovascular risk factors (increased age, diabetes, hypertension, smoking, obesity, strong family history of CAD), perform cardiovascular evaluation before prescribing triptans 2
• If evidence of CAD or coronary artery vasospasm exists, triptans are contraindicated 2
• Consider administering first dose in medically supervised setting with ECG monitoring for high-risk patients 2