What medication can be given to a patient with migraines not responding to NSAIDs?

Treatment Options When Migraine Does Not Respond to NSAIDs

When NSAIDs like Naxdom fail to control migraine, escalate immediately to triptans as first-line therapy, with sumatriptan 50-100 mg or rizatriptan 10 mg being the most evidence-based choices. 1

Immediate Next Steps: Triptan Therapy

• Start with oral sumatriptan 50-100 mg at migraine onset - this provides headache response (reduction to mild or no pain) in 61-62% of patients at 2 hours and 78-79% at 4 hours, compared to only 27-38% with placebo 2
• The 50 mg and 100 mg doses are equally effective, with 100 mg not providing additional benefit over 50 mg, so start with 50 mg to minimize side effects 2
• If headache persists or returns after 2 hours, a second dose may be taken with at least 2 hours between doses, maximum 200 mg in 24 hours 2
• Combine the triptan with an NSAID (such as naproxen 500 mg) for superior efficacy compared to either agent alone - this combination provides 130 more patients per 1000 achieving sustained pain relief at 48 hours 1

Alternative Triptans if Sumatriptan Fails

• Failure of one triptan does not predict failure of others - if sumatriptan is ineffective after 2-3 migraine episodes, switch to a different triptan 1, 3
• Rizatriptan 10 mg reaches peak concentration in 60-90 minutes, making it the fastest oral triptan 1
• Eletriptan 40 mg or zolmitriptan 2.5-5 mg are reportedly more effective with fewer adverse reactions than sumatriptan 1
• Studies show that changing triptans results in 25-81% pain relief rates even in patients with poor response to sumatriptan 3

Route of Administration Considerations

• For severe attacks with significant nausea/vomiting, use subcutaneous sumatriptan 6 mg - this provides the highest efficacy with 59% achieving complete pain relief by 2 hours and onset within 15 minutes 1, 4
• Intranasal sumatriptan 5-20 mg is useful when nausea prevents oral medication absorption 1
• Subcutaneous administration is particularly effective for patients who rapidly reach peak intensity 1

Parenteral Options for Severe Refractory Migraine

• IV metoclopramide 10 mg plus IV ketorolac 30 mg is the recommended first-line combination for severe migraine requiring emergency treatment 1
• Metoclopramide provides direct analgesic effects through central dopamine receptor antagonism, not just antiemetic benefit 1
• Ketorolac has rapid onset with approximately 6 hours duration and minimal rebound headache risk 5, 1
• Prochlorperazine 10 mg IV effectively relieves headache pain and is comparable to metoclopramide in efficacy 1
• Dihydroergotamine (DHE) intranasal or IV has good evidence for efficacy as monotherapy 1

Critical Frequency Limitation to Prevent Medication-Overuse Headache

• Limit all acute migraine medications to no more than 2 days per week to prevent medication-overuse headache, which paradoxically increases headache frequency and can lead to daily headaches 1, 6
• If requiring acute treatment more than twice weekly, initiate preventive therapy immediately with propranolol 80-240 mg/day, topiramate, or amitriptyline 30-150 mg/day 1

Medications to Absolutely Avoid

• Never use opioids (meperidine, hydromorphone) or butalbital-containing compounds for migraine treatment - they have questionable efficacy, lead to dependency, cause rebound headaches, and result in loss of efficacy over time 5, 1, 6
• Reserve opioids only for cases where all other medications are contraindicated, sedation is not a concern, and abuse risk has been addressed 1

Newer Alternative Options if All Triptans Fail

• CGRP antagonists (gepants) such as ubrogepant 50-100 mg or rimegepant are recommended when triptans are contraindicated or ineffective after adequate trials 1
• These have no vasoconstriction, making them safe for patients with cardiovascular disease, uncontrolled hypertension, or cerebrovascular disease 1
• Lasmiditan 50-200 mg is a 5-HT1F receptor agonist without vasoconstrictor activity, useful when cardiovascular contraindications exist, though patients cannot drive for 8 hours after use 1