I have acute viral pharyngitis and am experiencing migraine headaches; what acute treatment options are safe and effective for the migraines?

Acute Migraine Treatment in the Setting of Viral Pharyngitis

For acute migraine relief while managing viral pharyngitis, start with acetaminophen 1000 mg or an NSAID (ibuprofen 400–800 mg or naproxen 500–825 mg) as first-line therapy, and escalate to a triptan (sumatriptan 50–100 mg) if the headache is moderate-to-severe or if NSAIDs fail after 2–3 episodes. 1, 2

First-Line Acute Treatment Algorithm

Mild-to-Moderate Migraine

• NSAIDs are the recommended first-line therapy for mild-to-moderate migraine attacks, with strong evidence supporting ibuprofen 400–800 mg, naproxen sodium 500–825 mg, or aspirin 1000 mg. 1, 2, 3
• Acetaminophen 1000 mg is an effective alternative when NSAIDs are contraindicated or not tolerated, though it demonstrates lower efficacy than NSAIDs. 1
• Combination therapy with acetaminophen 1000 mg + aspirin 500–1000 mg + caffeine 130 mg provides superior efficacy to single agents for mild-to-moderate attacks, achieving pain reduction in 59.3% of patients at 2 hours. 1

Moderate-to-Severe Migraine

• Triptans are first-line therapy for moderate-to-severe migraine or when NSAIDs fail after 2–3 episodes. 1, 2, 3
• Sumatriptan 50–100 mg is the most commonly used triptan with strong evidence for efficacy. 2, 4, 3
• 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
• Combination therapy of sumatriptan 50–100 mg PLUS naproxen 500 mg is superior to either agent alone, with 130 additional patients per 1,000 achieving sustained pain relief at 48 hours. 1

Critical Timing and Administration

• Take medication as early as possible during the attack while pain is still mild to maximize effectiveness; early treatment results in approximately 50% pain-free response at 2 hours versus only 28% when delayed until pain is moderate-to-severe. 1, 2
• Non-oral routes (intranasal sumatriptan 5–20 mg or subcutaneous sumatriptan 6 mg) should be considered when significant nausea or vomiting is present. 1, 2

Adjunctive Antiemetic Therapy

• Metoclopramide 10 mg (oral or IV) provides synergistic analgesia beyond its antiemetic properties through central dopamine receptor antagonism and should be given 20–30 minutes before or concurrently with NSAIDs or acetaminophen. 1
• Prochlorperazine 10 mg (oral or IV) is equally effective to metoclopramide for both headache pain and nausea. 1

Medication-Overuse Headache Prevention

• Strictly limit all acute migraine medications to ≤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 required more than twice weekly, initiate preventive therapy immediately rather than increasing the frequency of acute medications. 1

Medications to Absolutely Avoid

• Opioids (hydrocodone, oxycodone, codeine, tramadol) are contraindicated for migraine treatment because they provide questionable efficacy, carry high risk of dependence, precipitate rebound headaches, and worsen long-term outcomes. 1, 3
• Butalbital-containing compounds should be avoided due to high risk of medication-overuse headache and dependency. 1

When to Escalate Therapy

• If one triptan fails after 2–3 headache episodes, try a different triptan before abandoning the class entirely, as failure of one does not predict failure of others. 1, 2
• Third-line options for refractory migraine include gepants (ubrogepant 50–100 mg, rimegepant) or ditans (lasmiditan 50–200 mg), which are CGRP antagonists and 5-HT1F agonists respectively, safe for patients with cardiovascular contraindications to triptans. 1, 2

Special Considerations with Concurrent Pharyngitis

• Adequate hydration is essential both for viral pharyngitis recovery and migraine management; dehydration can worsen both conditions. 1
• NSAIDs provide dual benefit by addressing both migraine pain and pharyngitis-related inflammation, making them particularly appropriate in this clinical scenario. 1, 3
• Avoid excessive caffeine intake beyond the combination analgesic formulation, as it may worsen dehydration in the setting of viral illness. 1