What is the best course of treatment for a patient with a history of migraines, currently experiencing severe symptoms including nausea, photophobia, and pulsating headache, exacerbated by movement, and suspected to be triggered by irregular sleep, eating patterns, and stress?

Acute Severe Migraine Treatment via Telehealth

For this patient with severe migraine presenting with nausea, photophobia, and pulsating headache worsened by movement, prescribe sumatriptan 50-100 mg PLUS naproxen sodium 500 mg to be taken immediately, with instructions to treat early in future attacks and strict limitation to no more than 2 days per week to prevent medication-overuse headache. 1

Immediate Treatment Strategy

Combination therapy with triptan plus NSAID is superior to either agent alone and represents the strongest evidence-based recommendation for moderate to severe migraine. 1 This combination provides 130 more patients per 1000 achieving sustained pain relief at 48 hours compared to monotherapy. 1

Specific Prescribing Instructions

• Sumatriptan 50-100 mg orally at migraine onset - doses of 50 mg and 100 mg provide greater effect than 25 mg, though 100 mg may not provide greater effect than 50 mg. 2
• Naproxen sodium 500-825 mg taken simultaneously with the triptan for synergistic effect. 1
• If headache persists after 2 hours, a second dose of sumatriptan may be taken, but must wait at least 2 hours between doses with maximum 200 mg in 24 hours. 2
• Treat early in the attack while pain is still mild for maximum effectiveness - this is critical for optimal response. 3, 1

Adjunctive Antiemetic Therapy

Given the prominent nausea, add metoclopramide 10 mg orally to be taken 20-30 minutes before the triptan-NSAID combination. 1 Metoclopramide provides direct analgesic effects through central dopamine receptor antagonism beyond its antiemetic properties, and its prokinetic effects enhance absorption of co-administered medications. 1

Critical Frequency Limitation

Strictly limit all acute migraine medications to no more than 2 days per week (10 days per month) to prevent medication-overuse headache (MOH). 1 MOH paradoxically increases headache frequency and can lead to daily headaches, creating a vicious cycle. 3 If the patient requires acute treatment more than twice weekly, preventive therapy must be initiated immediately. 1

Addressing Modifiable Triggers

Counsel the patient on lifestyle modifications targeting their identified triggers: 3

• Regular sleep schedule - irregular sleep is a major modifiable trigger that must be addressed. 3
• Consistent meal timing - skipping meals or irregular eating patterns trigger attacks. 3
• Stress management techniques including relaxation training, meditative therapy (abdominal breathing exercises), progressive muscle relaxation, or cognitive-behavioral therapy. 3
• Maintain a headache diary to track attack frequency, triggers, and medication use - this provides a helpful tool for gauging improvement and identifying medication overuse. 3

When to Escalate Treatment

If sumatriptan fails after 2-3 headache episodes, try a different triptan - failure of one triptan does not predict failure of others. 1 Alternative options include:

• 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 - reportedly more effective with fewer adverse reactions than sumatriptan. 1
• Subcutaneous sumatriptan 6 mg - provides highest efficacy with onset within 15 minutes if oral formulations fail. 1

If all triptans fail after adequate trials, escalate to CGRP antagonists (gepants) such as ubrogepant 50-100 mg or rimegepant, which have no vasoconstriction and are safe for patients with cardiovascular contraindications. 1

Indications for Preventive Therapy

Initiate preventive therapy if: 3

• Two or more attacks per month producing disability lasting 3+ days. 3
• Use of acute medications more than twice per week. 1
• This current episode being "more severe than previous ones" suggests possible progression toward chronic migraine. 3

First-line preventive options include propranolol 80-240 mg/day, topiramate, or amitriptyline 30-150 mg/day (particularly useful for mixed migraine and tension-type headache). 3 Preventive therapy requires 2-3 months to assess efficacy. 4

Contraindications to Screen For

Before prescribing triptans, confirm the patient does NOT have: 1

• Ischemic heart disease or previous myocardial infarction
• Uncontrolled hypertension
• Cerebrovascular disease
• Vasospastic coronary disease

NSAIDs should be avoided if: 1

• Renal impairment (creatinine clearance <30 mL/min)
• Active GI bleeding or peptic ulcer disease
• Aspirin/NSAID-induced asthma

Work Absence Documentation

Provide medical certificate for work absence given the severity of symptoms (nausea, photophobia, pulsating pain worsened by movement) which are disabling and prevent normal function. 3 Migraine causes significant impairment in quality of life and work performance. 3

Critical Pitfall to Avoid

Do not allow the patient to increase frequency of acute medication use in response to treatment failure - this creates the vicious cycle of MOH. 1 Instead, transition to preventive therapy while optimizing the acute treatment strategy. 1 The patient must understand that migraine is a neurological disorder with a biological basis requiring a multimodal approach, and expectations for symptom resolution should be realistic as recovery may be gradual. 3