What are the treatment options for a patient experiencing symptoms of migraine, including severe headache, sensitivity to light and sound, nausea, and vomiting?

Treatment of Migraine Symptoms

For patients experiencing migraine with severe headache, photophobia, phonophobia, nausea, and vomiting, start with combination therapy of a triptan plus an NSAID (or acetaminophen if NSAIDs are contraindicated), and use non-oral routes when vomiting is present. 1

Acute Treatment Algorithm Based on Severity

Mild to Moderate Migraine (Without Vomiting)

• Start with NSAIDs as first-line therapy: ibuprofen 400-800 mg, naproxen 500-825 mg, or aspirin 1000 mg 1, 2
• Alternatively, use acetaminophen 1000 mg if NSAIDs are contraindicated 1
• Consider combination therapy with aspirin + acetaminophen + caffeine for enhanced efficacy 2
• If inadequate response after 2-3 attacks, escalate to triptan + NSAID combination 1

Moderate to Severe Migraine (Without Vomiting)

• Use combination therapy immediately: oral triptan (sumatriptan 50-100 mg, rizatriptan, or eletriptan) PLUS naproxen 500 mg or ibuprofen 400-800 mg 1, 2
• This combination provides 130 more patients per 1000 achieving sustained pain relief at 48 hours compared to either agent alone 2
• Begin treatment as early as possible when headache is still mild to maximize effectiveness 1, 3

Severe Migraine With Vomiting (Requires Non-Oral Route)

• First-line IV combination: metoclopramide 10 mg IV + ketorolac 30 mg IV 2, 4
  • This treats pain, nausea, and vomiting simultaneously with rapid onset and minimal rebound risk 4
• Alternative subcutaneous option: sumatriptan 6 mg subcutaneously provides the highest efficacy with 70-82% pain relief within 15 minutes 2, 4, 3
• Intranasal option: sumatriptan 5-20 mg nasal spray when IV access is unavailable 2
• Do not use oral medications when active vomiting is present as gastroparesis prevents adequate absorption 4

Managing Associated Symptoms

Nausea and Vomiting

• Add antiemetic 20-30 minutes before analgesic when nausea is present even without vomiting, as nausea itself is highly disabling 2, 4
• Metoclopramide 10 mg provides direct analgesic effects through central dopamine receptor antagonism beyond its antiemetic properties 2
• Prochlorperazine 10 mg IV is equally effective as metoclopramide with comparable efficacy 2

Photophobia and Phonophobia

• These symptoms typically resolve with effective headache treatment 3
• Lower incidence of photophobia and phonophobia occurs at 2-4 hours following sumatriptan administration compared to placebo 3

Critical Frequency Limitations to Prevent Medication Overuse Headache

Restrict all acute migraine medications to no more than 2 days per week (10 days per month maximum) to prevent medication overuse headache, which paradoxically increases headache frequency and can lead to daily headaches 1, 2, 3

• NSAIDs trigger medication overuse headache at ≥15 days per month 1
• Triptans trigger medication overuse headache at ≥10 days per month 1, 3
• If requiring acute treatment more than twice weekly, initiate preventive therapy immediately 1, 2

When First-Line Treatments Fail

Second-Line Options for Triptan + NSAID Failure

• CGRP antagonists (gepants): rimegepant, ubrogepant, or zavegepant for patients who do not tolerate or have inadequate response to combination therapy 1
• Ditan: lasmiditan for patients who fail all other treatments, though patients cannot drive for 8 hours after dosing due to CNS effects 1, 2
• Ergot alkaloid: dihydroergotamine (DHE) intranasal or IV has good efficacy evidence 1, 2

Medications to Absolutely Avoid

Do not use opioids or butalbital-containing compounds for acute migraine treatment as they lead to dependency, rebound headaches, and loss of efficacy over time 1, 2, 3

Preventive Therapy Indications

Initiate preventive therapy when:

• Migraine attacks occur ≥2 days per week 1, 2
• Attacks produce disability lasting ≥3 days per month 2
• Acute medications are being overused 1
• Acute treatments consistently fail or are contraindicated 2

First-Line Preventive Options

• Beta-blockers: propranolol 80-240 mg/day or timolol 20-30 mg/day 2, 5
• Antiepileptics: topiramate or divalproex sodium 500-1500 mg/day (avoid in women of childbearing potential due to teratogenic risk) 2, 5
• Tricyclic antidepressants: amitriptyline 30-150 mg/day, particularly for mixed migraine and tension-type headache 2, 5

Important Contraindications and Safety Considerations

Triptan Contraindications

Triptans are contraindicated in patients with 3:

• Ischemic heart disease or previous myocardial infarction
• Wolff-Parkinson-White syndrome or cardiac accessory pathway disorders
• Uncontrolled hypertension
• History of stroke or transient ischemic attack
• Prinzmetal's variant angina
• Peripheral vascular disease

Pregnancy and Lactation

Discuss adverse effects of pharmacologic treatments during pregnancy and lactation before initiating therapy, with valproate strictly contraindicated due to teratogenic risk 1, 2

Common Pitfalls to Avoid

• Do not delay treatment: Begin therapy at the earliest signs of headache while pain is still mild for maximum effectiveness 1, 3
• Do not use oral medications when vomiting is present: Gastroparesis prevents adequate absorption 4
• Do not reserve antiemetics only for vomiting patients: Nausea itself justifies treatment as it is highly disabling 2, 4
• Do not allow patients to increase acute medication frequency in response to treatment failure: This creates medication overuse headache; instead transition to preventive therapy 2