What is the next step in managing a patient with a history of migraines, who has shown improvement in symptoms, recently experienced a single episode resolved with ibuprofen, and has normal laboratory results?

Continue Current Management with Ibuprofen and Monitor for Need of Preventive Therapy

This patient with improved migraine symptoms and infrequent attacks (one episode in recent weeks) that respond well to ibuprofen should continue their current acute treatment strategy with NSAIDs, but requires assessment for preventive therapy indications. 1

Acute Treatment Strategy

Continue ibuprofen as first-line acute therapy, as NSAIDs (including ibuprofen) are recommended first-line medications for acute episodic migraine with the strongest evidence for efficacy. 1

• The patient has demonstrated successful response to ibuprofen, which achieved complete resolution of their most recent attack. 1
• Ibuprofen should be taken early in the attack when headache is still mild, as effectiveness depends critically on timely use with appropriate dosing (typically 400-800 mg). 1, 2
• Ensure the patient is using adequate dosing—consider 400-600 mg as the therapeutic dose, not exceeding maximum daily limits. 1

Assessment for Preventive Therapy

This patient does NOT currently meet criteria for preventive therapy based on current attack frequency. 3

• Preventive therapy should be considered for patients experiencing ≥2 migraine attacks per month with disability lasting ≥3 days per month. 3
• The patient reports improved migraines with only one recent episode, suggesting less than 2 attacks per month currently. 3
• Preventive therapy is also indicated when acute medications are used more than twice per week (≥10 days/month for NSAIDs), which this patient does not meet. 3, 2

Medication Overuse Headache Prevention

Counsel the patient about medication overuse headache (MOH) thresholds to prevent this complication. 1

• MOH develops when NSAIDs are used ≥15 days per month for at least 3 months in patients with preexisting headache disorder. 1
• The patient's current infrequent use (one episode recently) is well below this threshold. 1
• Advise limiting NSAID use to fewer than 15 days per month to avoid MOH development. 1

When to Escalate Acute Treatment

If ibuprofen becomes inadequate, add a triptan to the NSAID regimen. 1

• Combination therapy with a triptan plus NSAID should be used if adequate doses of NSAIDs alone do not provide sufficient pain relief. 1
• Triptans are most effective when taken early in an attack during mild headache phase. 1
• Specific triptan choice (sumatriptan, rizatriptan, eletriptan, etc.) should be based on patient preference regarding route of administration and cost. 1

Lifestyle Modifications

Emphasize non-pharmacologic strategies to reduce attack frequency. 1

• Maintain adequate hydration, regular meals, and consistent sleep schedule. 1
• Engage in regular moderate-to-intense aerobic exercise. 1
• Manage stress through relaxation techniques or mindfulness practices. 1
• Identify and avoid individual migraine triggers through detailed history. 1

Follow-Up Plan

Schedule follow-up in 2-3 months to reassess attack frequency and treatment response. 1

• Use headache diaries to track attack frequency, severity, duration, and medication use. 1, 3
• Reassess for preventive therapy indications if attack frequency increases to ≥2 disabling attacks per month. 3, 2
• Monitor for adequate response to acute treatment using validated tools like the Migraine Treatment Optimization Questionnaire (mTOQ-4). 1

Critical Pitfalls to Avoid

• Do not prescribe opioids or butalbital for acute migraine treatment, as these have questionable efficacy and significant risks of dependency. 1
• Do not initiate preventive therapy prematurely when acute treatment is working well and attack frequency is low (currently <2 attacks/month). 3
• Do not allow undertreated attacks to progress—counsel early treatment at first sign of migraine for maximum efficacy. 1, 2
• Do not overlook red flags for secondary headaches, though this patient's normal labs and typical migraine pattern are reassuring. 1