Which migraine therapies are safe and which should be avoided in an adult with migraine who is tapering high‑dose prednisone (60 mg), has sodium‑sensitive hypertension, and allergies to diphenhydramine, all opioids, and lisinopril?

Migraine Treatment in a Patient Tapering Prednisone with Sodium-Sensitive Hypertension and Multiple Drug Allergies

Safe First-Line Acute Therapies

Acetaminophen 1000 mg is your safest first-line option because it does not raise blood pressure or cardiovascular risk in patients with uncontrolled hypertension. 1

• Acetaminophen provides statistically significant pain relief for moderate to severe headache with a number-needed-to-treat of 22, but the full 1000 mg dose is required—lower doses (500–650 mg) have not demonstrated benefit. 1
• Limit acetaminophen use to no more than 2 days per week to prevent medication-overuse headache. 1

NSAIDs: Use with Extreme Caution

NSAIDs (ibuprofen, naproxen, ketorolac) should be avoided or used with extreme caution because sodium-sensitive hypertension is a relative contraindication—NSAIDs can further elevate blood pressure and increase cardiovascular risk. 1

• If blood pressure becomes well-controlled, NSAIDs may be reconsidered because they demonstrate superior efficacy to acetaminophen for most headache types. 1
• When NSAIDs are used, naproxen 500–825 mg or ibuprofen 400–800 mg are first-line options, but ketorolac should be used with particular caution in patients with renal impairment or cardiovascular disease. 1

Triptan Therapy: Safe and Effective

Triptans are safe and appropriate for moderate-to-severe migraine in this patient because the lisinopril allergy does not contraindicate triptans—triptans are contraindicated only in ischemic heart disease, uncontrolled hypertension, and cerebrovascular disease, not ACE inhibitor allergy. 2, 1

• Oral triptans with strong evidence include sumatriptan 50–100 mg, rizatriptan 10 mg, eletriptan 40 mg, and zolmitriptan 2.5–5 mg. 1
• Subcutaneous sumatriptan 6 mg provides the highest efficacy (59% pain-free at 2 hours) with onset within 15 minutes, particularly useful for severe attacks or when nausea is prominent. 1
• Intranasal sumatriptan 5–20 mg is an alternative when oral administration is compromised by nausea. 1
• Limit triptan use to ≤2 days per week (≤10 days per month) to prevent medication-overuse headache. 1

CGRP Antagonists (Gepants): Third-Line Option

Rimegepant or ubrogepant are recommended as third-line alternatives when triptans fail or are contraindicated, because gepants have no vasoconstriction and are safe in cardiovascular disease. 3, 4

• Rimegepant 75 mg orally disintegrating tablet is taken as a single dose; avoid another dose within 48 hours when used with moderate CYP3A4 inhibitors. 4
• Ubrogepant 50–100 mg is an alternative gepant with similar efficacy and safety profile. 1
• Limit gepant use to no more than 8 migraine attacks per 30-day period to prevent medication overuse. 1

Antiemetic Adjuncts: Safe and Synergistic

Metoclopramide 10 mg IV or oral provides synergistic analgesia beyond its antiemetic effect through central dopamine receptor antagonism. 1

• Metoclopramide is contraindicated in pheochromocytoma, seizure disorders, active GI bleeding, or GI obstruction. 1
• Prochlorperazine 10 mg IV or 25 mg oral/suppository is an alternative with comparable efficacy but carries additional risks of tardive dyskinesia, hypotension, and arrhythmias. 1
• Both agents should be limited to no more than twice weekly to prevent medication-overuse headache. 1

Absolutely Contraindicated Therapies

All opioids (including morphine, hydromorphone, codeine, tramadol) are absolutely contraindicated per your allergy history and should never be used for migraine treatment due to questionable efficacy, high risk of dependency, rebound headaches, and medication-overuse headache. 2, 1, 5

• Opioids are pro-nociceptive, prevent reversal of migraine central sensitization, interfere with triptan effectiveness, and precipitate transformation to chronic daily headache. 5
• Butalbital-containing compounds should also be avoided due to high risk of medication-overuse headache and dependency. 1

Diphenhydramine (Benadryl) is contraindicated per your allergy history and should not be used as an adjunct antiemetic. 1

Prednisone Taper Considerations

The prednisone taper itself does not contraindicate any of the recommended migraine therapies (acetaminophen, triptans, gepants, or antiemetics). 1

• Corticosteroids like prednisone have limited evidence for acute migraine treatment and are more appropriate for status migrainosus (headache >72 hours) rather than routine acute attacks. 1
• Once the prednisone taper is complete, reassess blood pressure control to determine if NSAIDs can be safely reintroduced. 1

Treatment Algorithm

1. Mild-to-moderate attacks: Start with acetaminophen 1000 mg at headache onset. 1
2. Moderate-to-severe attacks or acetaminophen failure: Escalate to oral triptan (sumatriptan 50–100 mg, rizatriptan 10 mg, or eletriptan 40 mg). 1
3. Severe attacks with rapid progression or prominent nausea: Use subcutaneous sumatriptan 6 mg or intranasal sumatriptan 5–20 mg. 1
4. Triptan failure after 2–3 episodes: Switch to a different triptan (failure of one does not predict failure of others). 3
5. All triptans fail: Escalate to gepant (rimegepant 75 mg or ubrogepant 50–100 mg). 3, 4
6. Nausea present: Add metoclopramide 10 mg or prochlorperazine 10–25 mg. 1
7. Frequent attacks (>2 days/week): Initiate preventive therapy immediately to avoid medication-overuse headache. 1

Critical Pitfalls to Avoid

• Do not use NSAIDs until blood pressure is well-controlled—sodium-sensitive hypertension is a relative contraindication. 1
• Do not exceed 2 days per week of acute medication use—this creates medication-overuse headache and transforms episodic migraine into chronic daily headache. 1
• Do not substitute opioids as rescue therapy—they worsen migraine outcomes and create dependency. 2, 5
• Do not delay preventive therapy if acute medications are needed more than twice weekly—this indicates inadequate migraine control. 1