What is the next best step for a patient with severe migraines worsening at night, not adequately controlled with sumatriptan (triptan) as needed, and a negative computed tomography (CT) head scan?

Next Best Step: Initiate Preventive Therapy

For a patient with severe migraines worsening at night, inadequately controlled with as-needed sumatriptan and a negative CT head, the next best step is to initiate preventive therapy immediately while optimizing acute treatment with combination therapy (triptan plus NSAID). 1

Why Preventive Therapy is Indicated Now

This patient meets clear criteria for preventive therapy:

• Inadequate control with acute medication indicates either insufficient efficacy or likely overuse of sumatriptan, both of which are indications for prevention 1
• Severe migraines suggest attacks producing significant disability, warranting preventive intervention 1
• The pattern of worsening at night may indicate increasing attack frequency or severity, further supporting the need for prevention 1

Critical warning: If this patient is using sumatriptan more than 2 days per week (10 days per month), they are at high risk for medication-overuse headache (MOH), which creates a vicious cycle of increasing headache frequency 1. This makes preventive therapy even more urgent.

First-Line Preventive Medication Options

Propranolol 80-240 mg/day is the first-line preventive medication with the strongest evidence base 1. Alternative first-line options include:

• Topiramate (dose titrated to effect, typically 50-100 mg/day) 1
• Amitriptyline 30-150 mg/day (particularly useful if the patient has mixed migraine and tension-type features) 1

Important: Preventive therapy requires 2-3 months for oral agents to demonstrate efficacy, so set appropriate expectations 1.

Optimize Acute Treatment Simultaneously

While initiating prevention, upgrade the acute treatment strategy:

Combination therapy with sumatriptan PLUS naproxen sodium 500 mg is superior to either agent alone, with 130 more patients per 1000 achieving sustained pain relief at 48 hours compared to monotherapy 1. This should be the new acute treatment approach.

Strict frequency limitation: Limit all acute medications to no more than 2 days per week to prevent MOH 1. If the patient needs acute treatment more frequently than this, it reinforces the urgency of preventive therapy.

Alternative Acute Options if Sumatriptan Continues to Fail

If sumatriptan remains inadequate even with NSAID combination:

• Try a different triptan (rizatriptan 10 mg, eletriptan 40 mg, or zolmitriptan 2.5-5 mg), as failure of one triptan does not predict failure of others 1
• Consider subcutaneous sumatriptan 6 mg if oral route is inadequate, which provides the highest efficacy (59% pain-free at 2 hours) with onset within 15 minutes 1, 2
• CGRP antagonists (gepants) such as ubrogepant 50-100 mg or rimegepant are third-line alternatives when triptans fail 1

Critical Pitfall to Avoid

Never allow the patient to increase the frequency of acute medication use in response to treatment failure 1. This creates MOH and worsens the underlying problem. Instead, transition immediately to preventive therapy while strictly limiting acute treatment to the most disabling episodes only 1.

What the Negative CT Tells Us

The negative CT appropriately rules out secondary causes of headache (mass lesion, hemorrhage, structural abnormality), allowing confident diagnosis of primary migraine disorder 1. This supports moving forward with aggressive migraine-specific management rather than further imaging.

Medications to Absolutely Avoid

Do not prescribe opioids or butalbital-containing compounds for this patient 1. These medications:

• Have questionable efficacy for migraine 1
• Lead to dependency and rebound headaches 1
• Result in loss of efficacy over time 1
• Increase risk of progression to chronic daily headache 3