What are the initial treatment recommendations for a patient experiencing severe migraine, considering their cardiovascular risk factors and potential comorbid conditions?

Severe Migraine Treatment

For severe migraine, initiate combination therapy with IV metoclopramide 10 mg plus IV ketorolac 30 mg as first-line treatment, providing rapid pain relief while minimizing side effects and rebound headache risk. 1

Initial Assessment for Cardiovascular Risk

Before administering migraine-specific medications, evaluate for cardiovascular contraindications:

• Absolute contraindications to triptans and DHE include: documented ischemic heart disease, coronary artery vasospasm (Prinzmetal's angina), uncontrolled hypertension, history of stroke or TIA, hemiplegic or basilar migraine, and Wolff-Parkinson-White syndrome 2, 3, 4
• For patients with multiple CV risk factors (age >40 in men or postmenopausal women, diabetes, hypertension, smoking, obesity, strong family history of CAD), perform cardiovascular evaluation before first triptan use 3, 4
• Approximately 20% of migraine patients have CV contraindications to triptans, with an additional 25% having ≥2 CV risk factors requiring caution 5

Treatment Algorithm Based on Cardiovascular Status

For Patients WITHOUT Cardiovascular Contraindications

First-Line IV Combination (Emergency/Urgent Care Setting):

• Metoclopramide 10 mg IV PLUS ketorolac 30 mg IV 1, 6
• This combination provides synergistic analgesia—metoclopramide offers direct analgesic effects through dopamine receptor antagonism beyond its antiemetic properties 1
• Ketorolac has rapid onset with 6-hour duration and minimal rebound headache risk 1

If inadequate response after 30-60 minutes:

• Add subcutaneous sumatriptan 6 mg (most rapid and effective route, with 59% achieving complete pain relief by 2 hours) 1, 7
• Alternative: IV dihydroergotamine (DHE) 1 mg 1, 6

Oral Outpatient Treatment:

• Sumatriptan 50-100 mg PLUS naproxen sodium 500 mg taken together at migraine onset 1
• This combination is superior to either agent alone, with 130 more patients per 1000 achieving sustained pain relief at 48 hours 1

For Patients WITH Cardiovascular Disease or Contraindications

Triptans and DHE are absolutely contraindicated 3, 4

First-Line Treatment:

• IV ketorolac 30 mg (60 mg IM if <65 years without renal impairment) 1
• PLUS IV metoclopramide 10 mg or prochlorperazine 10 mg 1, 6

Alternative Oral Options:

• CGRP antagonists (gepants): Ubrogepant 50-100 mg or rimegepant—these have no vasoconstriction and are safe with cardiovascular disease 1
• Lasmiditan 50-200 mg: A 5-HT1F receptor agonist without vasoconstrictor activity, but patients cannot drive for 8 hours after administration due to CNS effects 1

Critical Medication Frequency Limitation

Restrict ALL acute migraine medications to no more than 2 days per week (maximum 10 days per month) to prevent medication-overuse headache. 1, 7

• Medication-overuse headache presents as daily headaches or marked increase in migraine frequency 1, 3, 4
• If patients require acute treatment more than twice weekly, immediately initiate preventive therapy 1

Medications to Absolutely Avoid

• Opioids (including hydromorphone): Should only be reserved for cases where other medications cannot be used, sedation is not a concern, and abuse risk has been addressed 1
• Opioids lead to dependency, rebound headaches, and eventual loss of efficacy 1, 7
• Butalbital-containing compounds: Similar concerns for dependency and medication-overuse headache 7

Route Selection Based on Nausea/Vomiting

• When significant nausea or vomiting is present: Use non-oral routes (IV, subcutaneous, intranasal, or rectal) 2, 1
• Subcutaneous sumatriptan 6 mg provides fastest onset (15 minutes to peak concentration) and highest efficacy among all triptan formulations 1, 8
• Intranasal sumatriptan 5-20 mg is an alternative when IV access is unavailable 1

Discharge Planning and Preventive Therapy Consideration

• Provide oral rescue medications: NSAID (naproxen 500-825 mg) plus antiemetic (metoclopramide 10 mg or prochlorperazine 25 mg) 1
• Initiate preventive therapy if: ≥2 attacks per month with ≥3 days disability, using acute medications >2 days/week, or contraindication/failure of acute treatments 9
• First-line preventive options include propranolol 80-240 mg/day, topiramate 50-100 mg/day, or candesartan 9

Common Pitfalls to Avoid

• Do not delay treatment: Triptans work best when taken early while headache is still mild 1
• Do not use prednisone routinely: Corticosteroids have limited evidence for acute migraine and are more appropriate for status migrainosus 1
• Do not allow patients to increase acute medication frequency in response to treatment failure—this creates a vicious cycle of medication-overuse headache; instead transition to preventive therapy 1
• Do not assume chest pressure with triptans is always cardiac: These sensations are usually non-cardiac in origin, but perform cardiac evaluation in high-risk patients 3