Is the outlined management plan appropriate for a 26‑year‑old female with a one‑day migraine‑type headache triggered by sleep loss, normal vital signs and neurologic exam, and no red‑flag features?

Yes, this management plan is appropriate and aligns with evidence-based guidelines for episodic migraine triggered by sleep deprivation.

Your approach correctly identifies this as an episodic migraine (not requiring neuroimaging or preventive therapy), appropriately recommends first-line acute treatment with NSAIDs/acetaminophen, and establishes proper safety-net instructions—all of which match current guideline recommendations for a low-risk presentation. 1

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Why This Plan Is Appropriate

Correct Exclusion of Red Flags

• You systematically ruled out secondary headache causes through careful history and physical examination, which is the essential first step before diagnosing primary headache disorders. 1
• The absence of thunderclap onset, atypical aura, head trauma, fever, impaired memory, focal neurological deficits, and normal vital signs/neurologic exam excludes the need for urgent neuroimaging or emergency evaluation. 1
• Neuroimaging is indicated only when red flags are present—your patient has none, so CT/MRI would be unnecessary and potentially harmful (radiation exposure, incidental findings causing alarm). 1

Appropriate Diagnosis: Episodic Migraine

• The clinical features—diffuse frontal headache with photophobia, recurrent pattern triggered by sleep deprivation, and similarity to prior episodes—fulfill diagnostic criteria for migraine without aura. 1
• This is episodic migraine (not chronic migraine), which is defined as fewer than 15 headache days per month; your patient has only 1 day of headache triggered by a known precipitant (shift change/sleep loss). 1

First-Line Acute Treatment Is Correct

• NSAIDs (naproxen) and acetaminophen (Tylenol) are guideline-recommended first-line therapy for mild-to-moderate migraine attacks. 1, 2, 3, 4
• Naproxen 500–825 mg at onset achieves pain-free response in approximately 1 in 11 patients (NNT = 11) and is most effective when taken early while pain is still mild. 2
• Acetaminophen 1000 mg is an appropriate alternative for patients who cannot tolerate NSAIDs. 2, 3
• Your instruction to take medication "as needed" for acute pain is appropriate for episodic migraine with infrequent attacks. 2

Headache Diary Recommendation Is Evidence-Based

• Recommending a headache journal (or smartphone notes) is a validated diagnostic aid that improves accuracy of attack frequency reporting and helps identify triggers. 1
• This is particularly important because patients often underreport milder headaches and may not recognize patterns without systematic tracking. 1

Trigger Avoidance and Lifestyle Counseling Are Appropriate

• Identifying and managing modifiable triggers—including sleep deprivation, stress, tobacco, and alcohol—is a core component of migraine management and can reduce attack frequency. 1, 5
• Your advice to increase exercise is supported by evidence showing that regular physical activity reduces migraine frequency. 5

Safety-Net Instructions Are Appropriate

• Your 48-hour follow-up threshold for persistent symptoms is reasonable for a first-time presentation with a clear trigger. 1
• Your red-flag return precautions (severe/worst headache, seizure, loss of consciousness) correctly identify emergent secondary headache warning signs. 1

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What You Did NOT Need to Do (And Why)

No Indication for Preventive Therapy

• Preventive therapy is indicated only when patients have ≥2 migraine attacks per month causing ≥3 days of disability, use acute medication >2 days per week, or have contraindications to acute treatment. 6, 5
• Your patient has one isolated attack triggered by a known precipitant (sleep loss from shift change)—this does not meet criteria for preventive therapy. 6, 5

No Indication for Triptan Therapy

• Triptans are first-line for moderate-to-severe migraine or when NSAIDs fail after 2–3 episodes. 1, 2, 3
• Your patient described this headache as "more mild" than her usual episodes, making NSAIDs the appropriate first choice. 2, 3
• If she returns after 2–3 failed NSAID trials, then escalate to a triptan (sumatriptan 50–100 mg or rizatriptan 10 mg). 2, 7, 3

No Indication for Neuroimaging

• MRI or CT is indicated only when red flags suggest secondary headache (thunderclap onset, progressive worsening, fever, focal deficits, age >50 with new-onset headache). 1
• Your patient has a recurrent pattern identical to prior episodes with a clear trigger—this strongly supports primary headache and makes imaging unnecessary. 1

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Critical Medication-Overuse Prevention Counseling (Add This)

One important addition: You should explicitly counsel the patient to limit acute medication use to no more than 2 days per week to prevent medication-overuse headache (MOH). 1, 2, 8

• Using NSAIDs, acetaminophen, or triptans ≥15 days per month (or ≥10 days per month for triptans/combination analgesics) can paradoxically increase headache frequency and lead to daily headaches. 1, 2, 8
• If she finds herself needing acute medication more than twice weekly, she should return for evaluation of preventive therapy rather than increasing medication frequency. 1, 2

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When to Escalate Treatment

If NSAIDs Fail After 2–3 Episodes

• Switch to a triptan: sumatriptan 50–100 mg, rizatriptan 10 mg, or eletriptan 40 mg at headache onset. 2, 7, 3
• Combination therapy (triptan + NSAID) is superior to either agent alone for moderate-to-severe attacks. 2, 3

If Attacks Become Frequent (>2 per Month)

• Initiate preventive therapy with propranolol 80–240 mg/day, topiramate (titrated to effect), or amitriptyline 30–150 mg/day. 6, 5
• Preventive therapy requires 2–3 months to demonstrate full efficacy. 7, 5

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Common Pitfalls to Avoid

• Do not prescribe opioids (hydrocodone, oxycodone) or butalbital-containing compounds for migraine—they have questionable efficacy, cause medication-overuse headache, lead to dependency, and worsen long-term outcomes. 2, 3, 4
• Do not order neuroimaging for typical recurrent migraine without red flags—this exposes the patient to unnecessary radiation, cost, and risk of incidental findings that trigger further unnecessary testing. 1
• Do not delay acute treatment—triptans and NSAIDs are most effective when taken early in the attack while pain is still mild. 2, 7, 3
• Do not allow the patient to increase acute medication frequency beyond 2 days per week—this creates a vicious cycle of medication-overuse headache; instead, transition to preventive therapy. 1, 2

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Summary Algorithm

1. Exclude red flags (thunderclap, fever, focal deficits, trauma) → If present, urgent imaging/evaluation. 1
2. Diagnose episodic migraine based on recurrent pattern, photophobia, and known trigger (sleep loss). 1
3. First-line acute treatment: Naproxen 500–825 mg or acetaminophen 1000 mg at onset. 2, 3
4. Limit acute medication to ≤2 days per week to prevent medication-overuse headache. 1, 2, 8
5. Recommend headache diary to track frequency and identify triggers. 1
6. Counsel on trigger avoidance (sleep hygiene, stress management, avoid tobacco/alcohol). 1, 5
7. Escalate to triptan if NSAIDs fail after 2–3 episodes. 2, 7, 3
8. Initiate preventive therapy if attacks occur >2 times per month or acute medication use exceeds 2 days per week. 6, 5