What is the best course of treatment for a 42-year-old female patient with a 2-day history of migraine, starting at the base of the neck on the left side and radiating to the temple and eye, who has not found relief with over-the-counter (OTC) medications?

Cervicogenic Headache vs. Migraine: Immediate Treatment Approach

This patient's presentation—headache originating at the base of the neck and radiating to the temple and eye—suggests cervicogenic headache or migraine with cervical involvement, and should be treated immediately with IV metoclopramide 10 mg plus IV ketorolac 30 mg, which provides rapid relief for both conditions while avoiding opioids and their associated risks. 1

Why This Presentation Requires Careful Consideration

• The neck-origin pattern raises the possibility of cervicogenic headache, but this can also occur in migraine (many migraineurs experience neck pain as part of their attack). 2
• Since OTC medications (likely NSAIDs and acetaminophen) have already failed after 2 days, this represents a moderate-to-severe attack requiring escalation beyond oral therapy. 1
• The 2-day duration without relief indicates this is not responding to first-line treatments and warrants parenteral therapy. 1

Immediate Treatment: IV Combination Therapy

The optimal acute treatment is IV metoclopramide 10 mg plus IV ketorolac 30 mg administered together. 1

• Metoclopramide 10 mg IV provides direct analgesic effects through central dopamine receptor antagonism, independent of its antiemetic properties, making it effective for migraine pain itself. 1, 3
• Ketorolac 30 mg IV has rapid onset (approximately 15 minutes) with 6 hours duration and minimal rebound headache risk. 1
• This combination addresses both the headache pain and any accompanying nausea while avoiding opioids. 1

Alternative IV Options if Contraindications Exist

• Prochlorperazine 10 mg IV can substitute for metoclopramide with comparable efficacy (21% adverse event rate vs. 50% for chlorpromazine). 1, 3
• IV dihydroergotamine (DHE) has good evidence as monotherapy if NSAIDs are contraindicated. 1

Critical Contraindications to Screen For

• Ketorolac contraindications: Renal impairment (CrCl <30 mL/min), active GI bleeding, history of peptic ulcer disease, or significant cardiovascular disease. 1
• Metoclopramide/prochlorperazine contraindications: Pheochromocytoma, seizure disorder, GI obstruction, or CNS depression. 1, 3

Outpatient Bridge Therapy After IV Treatment

Prescribe sumatriptan 100 mg PLUS naproxen sodium 500 mg to be taken together at the first sign of future attacks. 1, 4

• This combination is superior to either agent alone, with 130 more patients per 1000 achieving sustained pain relief at 48 hours. 4
• The NSAID component prevents the 40% recurrence rate that occurs within 48 hours after triptan monotherapy. 4
• Both medications must be taken early in the attack while pain is still mild for maximum effectiveness. 1, 4

Alternative Oral Option: CGRP Antagonists (Gepants)

• Ubrogepant 50-100 mg is the primary alternative if triptans are contraindicated (cardiovascular disease, uncontrolled hypertension, cerebrovascular disease). 1, 5
• Gepants have no vasoconstriction, making them safe for patients with vascular contraindications. 1

Mandatory Frequency Limitation to Prevent Medication-Overuse Headache

Strictly limit ALL acute migraine medications to no more than 2 days per week (10 days per month for triptans, 15 days per month for NSAIDs). 1, 4

• Exceeding this frequency causes medication-overuse headache (MOH), which paradoxically increases headache frequency and can lead to daily chronic headaches. 1, 4
• If this patient requires acute treatment more than twice weekly, initiate preventive therapy immediately rather than increasing acute medication frequency. 1, 4

When to Initiate Preventive Therapy

Start preventive therapy NOW if any of the following apply: 1

• Headaches occur more than 2 days per week
• Two or more attacks per month producing disability lasting 3+ days
• Continued impairment in quality of life despite optimized acute therapy
• Contraindication to or failure of acute treatments

First-Line Preventive Options

• Propranolol 80-240 mg/day (avoid in asthma, heart block, or severe depression). 1
• Topiramate (effective but monitor for cognitive side effects and teratogenicity in women of childbearing age). 1
• Amitriptyline 30-150 mg/day (particularly useful if mixed migraine and tension-type headache). 1

Medications to Absolutely Avoid

Never prescribe opioids (hydromorphone, oxycodone, codeine) or butalbital-containing compounds for this patient. 1, 4

• These have questionable efficacy for migraine, lead to dependency, cause rebound headaches, and result in loss of efficacy over time. 1, 4
• Opioids should only be reserved for cases where all other medications are contraindicated AND the risk for abuse has been thoroughly addressed. 1

Red Flags Requiring Urgent Neuroimaging

• Thunderclap onset (sudden severe headache reaching peak intensity within seconds to minutes)
• Progressive worsening over days to weeks despite treatment
• Fever with neck stiffness
• New neurological deficits beyond typical aura
• First severe headache after age 50

If any red flags are present, obtain urgent CT or MRI before treating as primary headache. 1