What acute and preventive medications are recommended for an 18‑year‑old with migraine, including considerations for contraindications and criteria for initiating prophylaxis?

Migraine Treatment for an 18-Year-Old

For an 18-year-old with migraine, start with ibuprofen 400–800 mg or naproxen sodium 500–825 mg as first-line therapy for mild-to-moderate attacks, and escalate to a triptan (sumatriptan 50–100 mg, rizatriptan 10 mg, or nasal sumatriptan/zolmitriptan) for moderate-to-severe attacks or when NSAIDs fail after 2–3 episodes. 1, 2

Acute Treatment Algorithm

First-Line: NSAIDs for Mild-to-Moderate Attacks

• Ibuprofen 400–800 mg or naproxen sodium 500–825 mg should be taken at migraine onset, ideally when pain is still mild. 1, 3
• Aspirin 1000 mg or the combination of acetaminophen 1000 mg + aspirin 500–1000 mg + caffeine 130 mg are alternative first-line options with strong evidence. 1, 3
• Take medication early in the attack while headache is mild—this increases pain-free response at 2 hours from approximately 28% to 50%. 3

Second-Line: Triptans for Moderate-to-Severe Attacks

• Sumatriptan 50–100 mg, rizatriptan 10 mg, or zolmitriptan 2.5–5 mg are recommended when NSAIDs fail or for attacks that start at moderate-to-severe intensity. 1, 2
• For adolescents aged 12–17 years (and applicable to 18-year-olds), nasal spray formulations of sumatriptan (5–20 mg) and zolmitriptan provide the most effective triptan delivery and are particularly useful when nausea is prominent. 1, 2
• Subcutaneous sumatriptan 6 mg provides the highest efficacy (59% pain-free at 2 hours) with onset within 15 minutes, reserved for severe attacks with rapid progression or significant vomiting. 1, 3

Combination Therapy for Enhanced Efficacy

• Sumatriptan 50–100 mg PLUS naproxen sodium 500 mg is superior to either agent alone, with 130 additional patients per 1,000 achieving sustained pain relief at 48 hours. 3, 4
• This combination represents the strongest-rated intervention for moderate-to-severe migraine with a number-needed-to-treat of 3.5. 3

Adjunctive Treatment for Nausea

• Metoclopramide 10 mg or prochlorperazine 25 mg should be added 20–30 minutes before the analgesic when nausea is a prominent symptom, as these provide synergistic analgesia beyond their antiemetic effects. 1, 3
• Nausea itself is one of the most disabling migraine symptoms and warrants direct treatment, not just in patients who are vomiting. 1, 3

Critical Frequency Limitation to Prevent Medication-Overuse Headache

• Limit all acute migraine medications to no more than 2 days per week (≤10 days per month) to prevent medication-overuse headache, which paradoxically increases headache frequency and can lead to daily headaches. 1, 3, 4
• This 2-day-per-week limit is non-negotiable and applies to NSAIDs, triptans, combination analgesics, and all other acute treatments. 3
• If acute treatment is needed more than twice weekly, initiate preventive therapy immediately rather than increasing acute medication frequency. 1, 3

Indications for Preventive Therapy

Preventive therapy should be initiated if any of the following criteria are met: 1

• ≥2 migraine attacks per month producing disability lasting ≥3 days
• Use of acute medication more than twice per week
• Contraindication to or failure of acute treatments
• Presence of uncommon migraine conditions (hemiplegic migraine, prolonged aura, migrainous infarction)

First-Line Preventive Medications

• Propranolol 80–240 mg/day or timolol 20–30 mg/day (beta-blockers without intrinsic sympathomimetic activity) are recommended first-line preventive agents with strong randomized trial evidence. 1
• Amitriptyline 30–150 mg/day is preferred when comorbid depression, anxiety, or sleep disturbances are present, or for mixed migraine and tension-type headache. 1
• Topiramate or divalproex sodium 500–1500 mg/day are alternative first-line options, though valproate is strictly contraindicated in women of childbearing potential due to teratogenic risk. 1
• Preventive efficacy requires 2–3 months of treatment before assessing response. 1

Third-Line Options: Gepants (CGRP Antagonists)

• Ubrogepant 50–100 mg or rimegepant 75 mg should be reserved as third-line acute treatment for patients who have failed or have contraindications to the triptan + NSAID combination. 3, 2, 4
• Gepants have no vasoconstriction, making them safe for patients with cardiovascular disease or uncontrolled hypertension (contraindications for triptans). 3
• However, gepants are significantly more expensive (annualized cost $4,959–$5,994) compared to generic triptans and NSAIDs, so cost-effectiveness favors trying multiple triptans before escalating to gepants. 4

Medications to Absolutely Avoid

• Opioids (codeine, hydromorphone, oxycodone) and butalbital-containing compounds should never be used for migraine treatment in an 18-year-old, as they have questionable efficacy, cause medication-overuse headache, lead to dependency, and result in loss of efficacy over time. 1, 3
• These agents carry a two-fold higher risk of medication-overuse headache compared to NSAIDs and triptans. 3

Contraindications to Triptans

Triptans are contraindicated in patients with: 1, 3

• Ischemic heart disease, previous myocardial infarction, or coronary artery vasospasm
• Uncontrolled hypertension
• Cerebrovascular disease, history of stroke or TIA
• Basilar or hemiplegic migraine
• Significant cardiovascular disease or cardiovascular risk factors requiring assessment

Special Considerations for Adolescents and Young Adults

• The evidence base for medication therapy in adolescents is confounded by high placebo response in clinical trials, resulting in low apparent therapeutic gain. 1
• Despite this, multiple NSAIDs and triptans have been approved for adolescents aged 12–17 years, with nasal spray formulations showing the most consistent benefit. 1, 2
• Bed rest alone may suffice for very short-duration attacks in younger patients. 1, 2
• Education of the patient and family members about trigger avoidance, medication limits, and when to seek specialist care is essential. 1

When to Refer to Specialist Care

• If acute medication provides insufficient pain relief after adequate trials of NSAIDs and at least 2–3 different triptans. 1
• If preventive therapy is needed but first-line oral agents fail or are contraindicated. 1
• If headaches occur more than 15 days per month (chronic migraine), requiring consideration of onabotulinumtoxinA or CGRP monoclonal antibodies. 3