What is the next best treatment option for an acute migraine attack in a patient with no history of cardiovascular disease, uncontrolled hypertension, or stroke, who has not responded to Tylenol (acetaminophen) and Motrin (ibuprofen)?

Next-Step Treatment for Acute Migraine After NSAID Failure

For patients who have failed acetaminophen and ibuprofen, the next best treatment is a triptan—specifically oral sumatriptan 50-100 mg combined with naproxen sodium 500 mg, which provides superior efficacy compared to either agent alone. 1

First-Line Escalation: Triptan Therapy

• Triptans are recommended as first-line therapy for moderate to severe migraine attacks and should be used when NSAIDs fail to provide adequate relief 1
• The combination of sumatriptan plus naproxen sodium is superior to either medication alone, with 65% of patients achieving 2-hour headache response versus 49% with sumatriptan alone or 46% with naproxen alone 1, 2
• Oral triptans with strong evidence include sumatriptan, rizatriptan, eletriptan, and zolmitriptan 1
• Take the triptan early in the attack while pain is still mild for maximum effectiveness—this significantly improves pain-free response rates compared to treating moderate or severe pain 1

Specific Dosing Recommendations

• Sumatriptan 50-100 mg orally is the standard dose, which can be repeated once after 2 hours if needed, with a maximum of 200 mg in 24 hours 3
• Naproxen sodium 500 mg should be taken concurrently with the triptan for synergistic benefit 1, 2
• If oral route is compromised by severe nausea or vomiting, subcutaneous sumatriptan 6 mg provides the highest efficacy with onset within 15 minutes 1

Alternative Triptan Options

• Rizatriptan, eletriptan, and zolmitriptan are equally effective alternatives if sumatriptan is not tolerated or available 1
• Intranasal sumatriptan (5-20 mg) is particularly useful when significant nausea or vomiting is present 1

Critical Contraindications to Screen For

• Do not prescribe triptans if the patient has: ischemic heart disease, uncontrolled hypertension, history of stroke or TIA, peripheral vascular disease, or hemiplegic/basilar migraine 3
• For patients with multiple cardiovascular risk factors (age >40, diabetes, hypertension, smoking, obesity, strong family history of CAD) who have never taken a triptan, consider administering the first dose in a supervised medical setting 3

Adjunctive Antiemetic Therapy

• Add metoclopramide 10 mg or prochlorperazine 10 mg 20-30 minutes before the triptan if nausea is present—these provide synergistic analgesia beyond their antiemetic effects 1
• Antiemetics are appropriate even without vomiting, as nausea itself is one of the most disabling migraine symptoms 1

Medication Frequency Limits

• 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
• If the patient requires acute treatment more than twice weekly, initiate preventive therapy immediately rather than increasing acute medication frequency 1

If Triptans Fail or Are Contraindicated

• IV metoclopramide 10 mg plus IV ketorolac 30 mg is the recommended first-line combination for severe attacks requiring parenteral treatment 1
• Intranasal dihydroergotamine (DHE) has good evidence for efficacy as monotherapy 1
• Avoid opioids—they should be reserved only for cases where other medications cannot be used, when sedation is not a concern, and when abuse risk has been addressed 1

Common Pitfalls to Avoid

• Do not wait until pain is severe to take the triptan—early administration while pain is mild significantly improves outcomes 1
• Do not allow patients to increase frequency of acute medication use in response to treatment failure—this creates medication-overuse headache 1
• Do not prescribe triptans without screening for cardiovascular contraindications, particularly in patients over 40 with risk factors 3
• Do not combine triptans with ergotamines or use another triptan within 24 hours 3