What treatment options are available for a patient with migraines whose dose of Lexapro (escitalopram) was recently increased from 5mg to 10mg?

Migraine Treatment Options for Patient on Increased Lexapro Dose

Start with NSAIDs (naproxen 500-825 mg or ibuprofen 400-800 mg) as first-line therapy for mild-to-moderate migraine attacks, and escalate to combination therapy with a triptan plus NSAID (such as sumatriptan 50-100 mg plus naproxen 500 mg) for moderate-to-severe attacks or when NSAIDs alone fail. 1, 2

First-Line Treatment Algorithm

For mild-to-moderate migraine:

• Naproxen sodium 500-825 mg at migraine onset (ideally when pain is still mild), which can be repeated every 2-6 hours as needed, with a maximum of 1.5 g per day 1
• Alternative NSAIDs include ibuprofen 400-800 mg or aspirin 1000 mg 1
• Consider adding metoclopramide 10 mg orally 20-30 minutes before the NSAID for synergistic analgesia and to address nausea 1

For moderate-to-severe migraine or NSAID failure:

• Combination therapy with sumatriptan 50-100 mg plus naproxen sodium 500 mg taken simultaneously at migraine onset provides superior efficacy, with 130 more patients per 1000 achieving sustained pain relief at 48 hours compared to either agent alone 2
• The NSAID component prevents the 40% recurrence rate that occurs within 48 hours after apparently successful triptan treatment 2
• Alternative oral triptans include rizatriptan 10 mg, naratriptan, or zolmitriptan 1

Critical Frequency Limitation

Strictly limit all acute migraine 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 For triptans specifically, the threshold is ≥10 days per month, and for NSAIDs, it's ≥15 days per month 2

When to Initiate Preventive Therapy

Immediately initiate preventive therapy if the patient requires acute treatment more than 2 days per week, has two or more attacks per month producing disability lasting 3+ days, or continues to have impaired quality of life despite optimized acute therapy. 1, 2

First-line preventive options include:

• Propranolol 80-240 mg/day (avoid in patients with asthma or heart block) 1, 2
• Topiramate (titrate slowly to minimize side effects) 1
• Divalproex sodium (avoid in women of childbearing potential due to teratogenic risk) 1
• Amitriptyline 30-150 mg/day, particularly useful for patients with mixed migraine and tension-type headache 1

Interaction Considerations with Lexapro

The dose increase of escitalopram from 5 mg to 10 mg is within the standard therapeutic range 3. There are no direct contraindications to using NSAIDs or triptans with SSRIs like escitalopram, though there is a theoretical increased risk of serotonin syndrome when combining triptans with SSRIs 3. This risk is generally low with standard dosing, but monitor for symptoms such as agitation, confusion, rapid heart rate, or muscle rigidity.

Medications to Absolutely Avoid

Never prescribe opioids (hydromorphone, oxycodone) or butalbital-containing compounds (Fioricet) for migraine treatment, as they have questionable efficacy, considerable adverse effects, risk of dependency, and lead to rebound headaches. 1, 2, 4

Alternative Routes for Severe Attacks with Vomiting

For patients with significant nausea or vomiting:

• Subcutaneous sumatriptan 6 mg provides the highest efficacy with onset within 15 minutes, achieving pain relief in 70-82% of patients 1
• Intranasal sumatriptan 5-20 mg or zolmitriptan nasal spray 1
• IV metoclopramide 10 mg plus IV ketorolac 30 mg for emergency department or urgent care settings 1

Common Pitfalls to Avoid

• Do not allow patients to increase frequency of acute medication use in response to treatment failure, as this creates a vicious cycle of medication-overuse headache; instead transition to preventive therapy while optimizing acute treatment strategy 1
• Timing is critical: both NSAIDs and triptans must be taken early in the attack while the headache is still mild for maximum effectiveness 2
• Failure of one triptan does not predict failure of others, so if the initial triptan is ineffective after 2-3 migraine episodes, switch to a different triptan before abandoning the class 1, 2