What acute and preventive treatment should be used for a 39‑year‑old woman with migraine?

Migraine Treatment for a 39-Year-Old Woman

Acute Treatment Strategy

For mild-to-moderate migraine attacks, start with NSAIDs (ibuprofen 400–800 mg, naproxen 500–825 mg, or aspirin 1000 mg) as first-line therapy; for moderate-to-severe attacks or when NSAIDs fail after 2–3 episodes, escalate immediately to combination therapy with a triptan (sumatriptan 50–100 mg) plus an NSAID (naproxen 500 mg), which is superior to either agent alone. 1, 2

First-Line Acute Therapy

• NSAIDs alone are appropriate for mild-to-moderate attacks, with ibuprofen 400–800 mg, naproxen 500–825 mg, or aspirin 1000 mg demonstrating proven efficacy. 1, 2
• Take medication early in the attack while pain is still mild to maximize effectiveness—approximately 50% of patients become pain-free at 2 hours when treated early versus only 28% when treatment is delayed until pain is moderate or severe. 1

Escalation to Combination Therapy

• Add a triptan to the NSAID regimen for moderate-to-severe attacks or after NSAID failure in 2–3 episodes. 1, 2
• Sumatriptan 50–100 mg plus naproxen 500 mg is the strongest-rated combination, yielding 130 additional patients per 1,000 who achieve sustained pain relief at 48 hours compared with sumatriptan alone (number-needed-to-treat of 3.5 for headache relief at 2 hours). 1
• Alternative oral triptans include rizatriptan 10 mg (fastest oral triptan, reaching peak concentration in 60–90 minutes), eletriptan 40 mg, or zolmitriptan 2.5–5 mg. 1

Non-Oral Routes for Severe Attacks or Prominent Nausea

• Subcutaneous sumatriptan 6 mg provides the highest efficacy (59% complete pain relief by 2 hours) with onset within 15 minutes, making it ideal for rapid progression or significant nausea/vomiting. 1
• Intranasal sumatriptan 5–20 mg or other nasal spray triptans are useful when oral absorption is impaired by gastroparesis. 1, 2

Adjunctive Antiemetic Therapy

• Add metoclopramide 10 mg or prochlorperazine 25 mg 20–30 minutes before the primary acute medication when nausea is present, as antiemetics provide synergistic analgesia beyond their antiemetic effects. 1, 2
• Metoclopramide improves gastric motility and enhances absorption of co-administered medications. 1

Critical Frequency Limitation

• 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, 2
• If acute treatment is needed more than twice weekly, initiate preventive therapy immediately. 1, 3

Contraindications to Triptans

• Triptans are contraindicated in ischemic heart disease, previous myocardial infarction, coronary artery vasospasm, uncontrolled hypertension, cerebrovascular disease, history of stroke or TIA, and basilar or hemiplegic migraine. 1

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Preventive Treatment Strategy

Preventive therapy is indicated when a patient experiences ≥2 migraine attacks per month with disability lasting ≥3 days, uses abortive medication more than twice per week, has contraindications to or failure of acute treatments, or has uncommon migraine conditions. 3

Indications for Preventive Therapy

• ≥2 migraine attacks per month with disability lasting ≥3 days per month. 3
• Use of abortive medication more than twice per week to avoid medication-overuse headache. 3
• Failure, contraindication to, or troublesome side effects from acute medications. 3, 4
• Patient preference for reducing attack frequency rather than treating individual attacks. 3, 4

First-Line Preventive Medications

• Propranolol 80–240 mg/day or timolol 20–30 mg/day are FDA-approved beta-blockers with strong randomized controlled trial evidence for migraine prophylaxis. 3, 5
• Topiramate 50–100 mg/day (typically 50 mg twice daily) has strong evidence for both episodic and chronic migraine prevention and is preferred in patients with obesity due to associated weight loss. 3, 5
• Candesartan is an effective first-line agent, particularly useful for patients with comorbid hypertension. 3

Second-Line Preventive Medications

• Amitriptyline 30–150 mg/day is preferred for patients with comorbid depression, anxiety, sleep disturbances, or mixed migraine and tension-type headache. 3, 5
• Sodium valproate 800–1500 mg/day or divalproex sodium 500–1500 mg/day are effective but strictly contraindicated in women of childbearing potential due to teratogenic risk. 3, 5

Third-Line Preventive Options

• CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab, eptinezumab) should be considered when 2–3 oral preventive medications have failed or are contraindicated, with efficacy assessed after 3–6 months. 3
• OnabotulinumtoxinA is the only FDA-approved therapy specifically for chronic migraine (≥15 headache days per month), administered as 155–195 units across 31–39 sites every 12 weeks, with efficacy assessed after 6–9 months. 1, 3

Implementation of Preventive Therapy

• Start with a low dose and titrate slowly until clinical benefits are achieved or side effects limit further increases. 3, 5
• Allow an adequate trial period of 2–3 months at the target dose before determining efficacy; for CGRP monoclonal antibodies, assess efficacy only after 3–6 months. 3
• Use headache diaries to track attack frequency, severity, duration, disability, treatment response, and adverse effects. 3

Common Pitfalls to Avoid

• Do not maintain sub-therapeutic doses (e.g., propranolol <160 mg or amitriptyline <30 mg) indefinitely; doses should be optimized before declaring treatment failure. 3
• Do not discontinue preventive therapy prematurely; an adequate trial requires 2–3 months at the target dose. 3
• Do not fail to recognize medication-overuse headache from frequent use of acute medications, which can interfere with preventive treatment. 3

Non-Pharmacological Adjuncts

• Cognitive behavioral therapy, biofeedback, and relaxation training are effective adjuncts to medication or stand-alone treatments when medications are contraindicated. 3, 6
• Identify and modify triggers such as sleep hygiene, regular meals, hydration, stress management, and avoidance of excessive caffeine. 3, 6

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Algorithm for Decision-Making

1. Assess attack frequency and severity:

   • If <2 attacks per month with mild-to-moderate severity → acute treatment only with NSAIDs or triptan-NSAID combination as needed. 1, 2
   • If ≥2 attacks per month with disability ≥3 days or acute medication use >2 days per week → initiate preventive therapy. 3

2. Select first-line preventive based on comorbidities:

   • Obesity present → topiramate 50–100 mg/day. 3
   • Depression, anxiety, or sleep disturbance → amitriptyline 30–150 mg/day. 3, 5
   • Hypertension → propranolol 80–240 mg/day or candesartan. 3
   • No significant comorbidities → propranolol 80–240 mg/day or topiramate 50–100 mg/day. 3

3. Trial preventive medication for 2–3 months at target dose:

   • If ≥50% reduction in monthly migraine days → continue therapy for 6–12 months, then consider pausing to determine if it can be discontinued. 3
   • If <50% reduction → switch to alternative first-line agent or escalate to second-line agent. 3

4. After failure of 2–3 oral preventives:

   • Escalate to CGRP monoclonal antibodies or onabotulinumtoxinA (if chronic migraine). 3

5. Strictly limit acute medication use to ≤2 days per week throughout preventive therapy. 1, 3

1, 2, 3, 4, 5, 7, 8, 6