What is the best treatment approach for a 30-year-old female patient with a 6-day intractable migraine that worsens when laying down, accompanied by diarrhea?

Urgent Neuroimaging Required Before Treatment

This 30-year-old female with a 6-day intractable migraine that worsens when lying down requires immediate neuroimaging (CT or MRI) before any symptomatic treatment, as this presentation raises concern for increased intracranial pressure or other secondary causes such as cerebral venous sinus thrombosis. 1

Critical Red Flags in This Presentation

• Headache worsening when lying down is a classic sign of increased intracranial pressure, which can indicate serious pathology including cerebral venous sinus thrombosis, intracranial mass, or idiopathic intracranial hypertension 1
• The 6-day duration qualifies as intractable migraine (status migrainosus), which itself warrants aggressive evaluation and treatment 2
• Diarrhea occurring with migraine is a recognized gastrointestinal symptom that occurs in migraineurs, but in this context of positional headache, secondary causes must be excluded first 3

Mandatory First Step: Neuroimaging

• Obtain CT head or MRI brain immediately before initiating any symptomatic treatment to rule out subarachnoid hemorrhage, intracranial mass, cerebral venous sinus thrombosis, or other life-threatening pathology 1
• MRI with venography is preferred if cerebral venous sinus thrombosis is suspected, given the positional nature and prolonged duration 1

Acute Treatment After Imaging Excludes Secondary Causes

First-Line IV Treatment for Intractable Migraine

If neuroimaging is normal, initiate IV metoclopramide 10 mg plus IV ketorolac 30 mg as first-line combination therapy for this severe, prolonged migraine attack. 2

• Metoclopramide provides direct analgesic effects through central dopamine receptor antagonism beyond its antiemetic properties, addressing both the headache and associated nausea/diarrhea 2
• Ketorolac has rapid onset with approximately 6 hours duration and minimal rebound headache risk 2
• This combination provides synergistic analgesia while minimizing side effects 2

Alternative IV Options if First-Line Fails

• Dihydroergotamine (DHE) IV or intranasal has strong evidence for efficacy in intractable migraine and status migrainosus 2
• Prochlorperazine 10 mg IV is comparable to metoclopramide in efficacy and can be substituted if metoclopramide is contraindicated 2

Oral Outpatient Transition

• Once acute symptoms improve, transition to sumatriptan 50-100 mg plus naproxen sodium 500 mg for any recurrent attacks, as this combination is superior to either agent alone 2, 4
• This combination provides 130 more patients per 1000 achieving sustained pain relief at 48 hours compared to monotherapy 2

Critical Management of Diarrhea

• The diarrhea is likely a migraine-associated gastrointestinal symptom, as gastrointestinal disturbances including diarrhea occur in nearly all migraineurs 3
• Ensure adequate hydration with IV fluids if the patient cannot tolerate oral intake, using 0.9% saline initially to restore circulation if there are signs of dehydration 5
• Metoclopramide will help address the gastrointestinal symptoms through its prokinetic effects 2

Preventive Therapy Initiation

This patient requires immediate initiation of preventive therapy given the 6-day intractable nature of this attack. 2

• Intractable migraine lasting 6 days meets criteria for preventive therapy (two or more attacks per month producing disability for 3+ days) 2
• Propranolol 80-240 mg/day is the first-line preventive medication with the strongest evidence for efficacy 2
• Alternative first-line options include topiramate or amitriptyline 30-150 mg/day, particularly if the patient has mixed migraine and tension-type features 6
• Preventive therapy requires 2-3 months for oral agents to demonstrate efficacy 2

Medication Frequency Limits to Prevent Medication-Overuse Headache

• Strictly limit all acute migraine medications to no more than 2 days per week to prevent medication-overuse headache, which can paradoxically increase headache frequency and lead to daily headaches 2
• If the patient requires acute treatment more than twice weekly, this is an absolute indication for preventive therapy 2

Critical Pitfalls to Avoid

• Never treat positional headache without neuroimaging first, as this can delay diagnosis of life-threatening conditions like cerebral venous sinus thrombosis 1
• Avoid opioids completely as they lead to dependency, rebound headaches, and loss of efficacy, particularly problematic in intractable migraine 2
• Do not allow escalation of acute medication frequency in response to treatment failure, as this creates a vicious cycle of medication-overuse headache 2
• Ensure the patient is not pregnant before initiating treatment, as this would completely change the treatment algorithm 7