In a 24-year-old woman with typical migraine without aura lasting all day, occurring every 1–2 weeks, severe throbbing pain (10/10) and occasional visual stars, normal neurological exam, who has tried paracetamol and co‑codamol (codeine/paracetamol) and refuses ibuprofen, what acute and preventive treatment options should be considered?

Acute and Preventive Treatment for Severe Recurrent Migraine Without Aura

This patient requires an immediate trial of a triptan (sumatriptan 50–100 mg or rizatriptan 10 mg) taken early in the attack, combined with naproxen 500–825 mg, and should be started on preventive therapy now given the frequency and severity of attacks. 1

Diagnosis Confirmation

This presentation is classic migraine without aura: 1

• Throbbing unilateral pain lasting all day (4–72 hours typical)
• Severe intensity (10/10) with photophobia (improves in dark room)
• Occasional visual "stars" (likely photopsia, not true aura since vision not lost)
• Frequency of every 1–2 weeks (episodic migraine: <15 days/month)
• Normal neurological examination excludes secondary causes

Acute Treatment Algorithm

First-Line: Triptan + NSAID Combination

Start with sumatriptan 50–100 mg PLUS naproxen sodium 500 mg at headache onset while pain is still mild. 1, 2 This combination is superior to either agent alone, with 130 more patients per 1000 achieving sustained pain relief at 48 hours compared to monotherapy. 2

Critical timing: Medication must be taken early in the headache phase—effectiveness depends entirely on early administration before pain becomes severe. 1

Alternative oral triptans if sumatriptan fails after 2–3 episodes: 1, 2, 3

• Rizatriptan 10 mg (fastest oral triptan, peak at 60–90 minutes)
• Eletriptan 40 mg (reportedly more effective with fewer adverse effects than sumatriptan)
• Zolmitriptan 2.5–5 mg

Failure of one triptan does not predict failure of others—each should be tried for 2–3 headache episodes before abandoning that specific agent. 1, 2

Adjunctive Antiemetic Therapy

Add metoclopramide 10 mg orally 20–30 minutes before the triptan/NSAID combination. 1, 2 Metoclopramide provides direct analgesic effects through central dopamine receptor antagonism beyond its antiemetic properties, and its prokinetic effects enhance absorption of co-administered medications. 2

Nausea itself is one of the most disabling symptoms of migraine and warrants treatment even when vomiting is absent. 1

Third-Line Options if Triptans Fail

If all triptans fail after adequate trials, escalate to: 1, 2

• Gepants (CGRP antagonists): Ubrogepant 50–100 mg or rimegepant—no vasoconstriction, safe in cardiovascular disease
• Ditans: Lasmiditan 50–200 mg (5-HT1F agonist without vasoconstrictor activity)—must not drive or operate machinery for 8 hours after intake 1

Medications to Absolutely Avoid

Never prescribe: 1, 2

• Opioids (codeine, co-codamol, hydromorphone)—questionable efficacy, high dependency risk, two-fold higher risk of medication-overuse headache
• Butalbital-containing compounds—high risk of medication-overuse headache
• Oral ergot alkaloids—poorly effective and potentially toxic

The patient's current use of co-codamol (codeine/paracetamol) should be discontinued immediately. 1, 2

Preventive Therapy: Mandatory Given Attack Frequency

This patient meets absolute criteria for preventive therapy: 1

• Attacks every 1–2 weeks = 2–4 attacks per month
• Severe disability (10/10 pain, cannot function)
• Each attack lasts all day (>3 days disability per month)

First-Line Preventive Medications

Start propranolol 80 mg daily, titrate to 160–240 mg/day over 4–6 weeks. 1 Propranolol has the strongest evidence among beta-blockers and is FDA-approved for migraine prevention. 1, 2

Alternative first-line options: 1

• Timolol 20–30 mg/day (strong evidence)
• Amitriptyline 30–150 mg/day (preferred if comorbid depression, anxiety, or insomnia)
• Divalproex sodium 500–1500 mg/day or sodium valproate 800–1500 mg/day (strictly contraindicated in women of childbearing potential due to teratogenic risk) 1, 2

Timeline for Preventive Efficacy Assessment

Efficacy cannot be judged before 2–3 months of therapeutic dosing. 1 Patients must be discouraged from abandoning treatment in early stages on grounds of apparent inefficacy. 1

If one preventive medication fails after adequate trial, switch to a different drug class—failure of one does not predict failure of others. 1

Critical Medication-Overuse Headache Prevention

Limit ALL acute migraine medications to no more than 2 days per week (≤10 days per month). 1, 2 This is non-negotiable.

Frequent use of acute medications—including triptans, NSAIDs, and especially opioids—paradoxically increases headache frequency and can lead to daily headaches (medication-overuse headache). 1, 2

If the patient requires acute treatment more than twice weekly, this signals inadequate preventive therapy and necessitates immediate escalation of prevention. 1, 2

Practical Implementation Plan

1. Discontinue co-codamol immediately 1, 2
2. Prescribe for acute attacks: Sumatriptan 50–100 mg + naproxen 500 mg, taken together at headache onset (maximum 2 days/week) 1, 2
3. Add metoclopramide 10 mg to take 20–30 minutes before the triptan/NSAID 1, 2
4. Start propranolol 80 mg daily, titrate to 160–240 mg/day over 4–6 weeks 1
5. Reassess at 8–12 weeks to evaluate preventive efficacy and acute medication response 1
6. Maintain headache diary to track attack frequency, severity, medication use, and triggers 1, 2

Common Pitfalls to Avoid

• Do not allow continued opioid use "because it works"—this perpetuates medication-overuse headache and guarantees treatment failure 1, 2
• Do not delay preventive therapy while trialing multiple acute strategies—this patient already meets criteria 1
• Do not abandon a triptan after single failure—try different triptans for 2–3 episodes each before declaring triptan class ineffective 1, 2
• Do not prescribe acute medications without strict frequency limits—exceeding 2 days/week creates medication-overuse headache 1, 2