What is the recommended treatment for a patient with a history of migraine fronto-temporal head attacks?

Treatment of Fronto-Temporal Migraine Attacks

For moderate to severe fronto-temporal migraine attacks, start with combination therapy of a triptan (sumatriptan 50-100 mg) plus an NSAID (naproxen 500 mg or ibuprofen 400-800 mg) taken as early as possible at headache onset. 1

First-Line Treatment Algorithm

Mild to Moderate Attacks

• NSAIDs are the initial treatment: Use ibuprofen 400-800 mg, naproxen sodium 500-825 mg, or aspirin 1000 mg at the first sign of headache 1, 2
• Acetaminophen 1000 mg is an alternative if NSAIDs are contraindicated 1
• Combination products containing aspirin, acetaminophen, and caffeine provide synergistic analgesia and are effective for attacks that respond poorly to NSAIDs alone 2

Moderate to Severe Attacks

• Combination therapy is superior to monotherapy: Triptan + NSAID provides 130 more patients per 1000 achieving sustained pain relief at 48 hours compared to either agent alone 1, 2
• Specific triptan options with strong evidence: Sumatriptan 50-100 mg, rizatriptan 10 mg, or naratriptan are first-line choices 2
• Take medication when pain is still mild rather than waiting for severe symptoms—early treatment is more effective and reduces recurrence rates 1, 3

Route Selection Based on Symptoms

Oral Route (Standard)

• Use oral triptans + NSAIDs for typical attacks without severe nausea 1, 2
• Sumatriptan tablets achieve headache response in 52-62% of patients at 2 hours and 65-79% at 4 hours 4

Non-Oral Routes (Severe Nausea/Vomiting Present)

• Subcutaneous sumatriptan 6 mg provides the highest efficacy: 59% complete pain relief by 2 hours with onset within 15 minutes 2
• Intranasal sumatriptan 5-20 mg is an alternative when significant nausea prevents oral administration 2
• Add an antiemetic (metoclopramide 10 mg or prochlorperazine 10 mg) for synergistic analgesia beyond just treating nausea 1, 2

Second-Line Options for Inadequate Response

If combination triptan + NSAID therapy fails after 2-3 attacks, escalate to: 1

• CGRP antagonists (gepants): Rimegepant, ubrogepant 50-100 mg, or zavegepant nasal spray—these have no vasoconstriction and are safe with cardiovascular disease 1, 2
• Dihydroergotamine (DHE): Intranasal or injectable formulations have good efficacy evidence 1, 2
• Lasmiditan (ditan): 50-200 mg for patients who cannot tolerate all other options, but patients cannot drive for 8 hours after dosing due to CNS effects 1, 2

Critical Frequency Limitation to Prevent Medication-Overuse Headache

Limit all acute migraine medications to no more than 2 days per week (10 days per month maximum): 1, 2

• Triptans cause medication-overuse headache at ≥10 days/month 1
• NSAIDs cause medication-overuse headache at ≥15 days/month 1
• If requiring acute treatment more frequently, initiate preventive therapy immediately (propranolol 80-240 mg/day, topiramate, or CGRP monoclonal antibodies) 1, 2

Medications to Absolutely Avoid

Do not use opioids or butalbital-containing compounds for migraine treatment: These lead to dependency, rebound headaches, loss of efficacy, and progression to chronic daily headache 1, 2, 5

Cardiovascular Screening Before Triptan Use

Triptans are contraindicated in patients with: 4

• Ischemic heart disease or previous myocardial infarction
• Prinzmetal's angina (coronary vasospasm)
• Uncontrolled hypertension
• Cerebrovascular disease (stroke, TIA)
• Peripheral vascular disease

For triptan-naive patients with multiple cardiovascular risk factors (age >50, diabetes, hypertension, smoking, obesity, strong family history of CAD), perform cardiovascular evaluation before prescribing and consider administering the first dose in a medically supervised setting with ECG monitoring 4

Special Populations

Pregnancy and Breastfeeding

• Discuss adverse effects of all pharmacologic treatments before initiating therapy 1
• Sumatriptan is Pregnancy Category C with evidence of embryolethality and fetal abnormalities in animal studies 4
• Infant exposure to sumatriptan can be minimized by avoiding breastfeeding for 12 hours after treatment 4

Hepatic Impairment

• Maximum single dose of sumatriptan should not exceed 50 mg in mild to moderate hepatic impairment 4
• Sumatriptan is contraindicated in severe hepatic impairment 4

When Preventive Therapy Is Warranted

Initiate preventive medications if: 1, 2

• Episodic migraine occurs frequently (≥2 attacks per month producing disability for ≥3 days)
• Treatment does not provide adequate response after optimized acute therapy
• Patient uses acute medications more than twice weekly
• Contraindication to or failure of acute treatments