What is the preferred treatment regimen for a patient with a history of migraine headaches presenting with a typical migraine episode?

From the Guidelines

For the treatment of acute episodic migraine headache, I recommend a combination of a triptan, such as sumatriptan 100 mg orally, and an NSAID, such as ibuprofen 600-800 mg orally, as the initial treatment cocktail of choice. This recommendation is based on the most recent guideline from the American College of Physicians, which suggests that if patients use an adequate dose of an NSAID or acetaminophen and still do not have sufficient pain relief, then add a triptan to an NSAID, or to acetaminophen when NSAIDs are contraindicated or not tolerated 1. The choice of a specific NSAID or triptan should be based on individualized decision making, taking into consideration patient preferences on such factors as route of administration and cost.

Key considerations for this treatment cocktail include:

• Starting treatment as soon as possible after the onset of migraine symptoms to improve efficacy 1
• Using combination therapy, such as a triptan with an NSAID or acetaminophen, to improve efficacy 1
• Avoiding the use of opioids or butalbital for the treatment of acute episodic migraine 1
• Considering the use of a nonoral triptan and an antiemetic in people having severe nausea or vomiting 1
• Counseling patients to begin treatment of migraine headache as soon as possible after its onset, and to be aware of medication overuse and potential adverse effects 1

In patients who do not tolerate or have inadequate response to combination therapy of a triptan and an NSAID or acetaminophen, consider using CGRP antagonists-gepants (rimegepant, ubrogepant, or zavegepant) or ergot alkaloid (dihydroergotamine) as alternative treatment options 1. Additionally, for patients with mild episodic migraine headache, consider treating with an NSAID, acetaminophen, or the combination of an NSAID and acetaminophen 1.

From the FDA Drug Label

INDICATIONS AND USAGE Dihydroergotamine Mesylate Injection is indicated for the acute treatment of migraine headaches with or without aura and the acute treatment of cluster headache episodes. INDICATIONS AND USAGE Dihydroergotamine Mesylate Injection, USP is indicated for the acute treatment of migraine headaches with or without aura and the acute treatment of cluster headache episodes.

The treatment of choice for a patient with a history of migraine headaches presenting with their typical presentation is dihydroergotamine. The route of administration can be either IV 2 or IM 3, depending on the clinical situation and patient's needs.

• Key points:
  • Dihydroergotamine is indicated for the acute treatment of migraine headaches with or without aura.
  • The choice between IV and IM administration should be based on clinical judgment and patient-specific factors.

From the Research

Migraine Treatment Cocktail

The treatment of migraine headaches often involves a combination of medications to provide effective relief. Based on the available evidence, a commonly used migraine treatment cocktail includes:

• Sumatriptan, a serotonin 5-HT1B/1D receptor agonist, which works by constricting blood vessels and blocking pain pathways in the brain 4, 5, 6, 7, 8
• Naproxen, a non-steroidal anti-inflammatory drug (NSAID), which helps to reduce inflammation and relieve pain 4, 5, 6, 7, 8

Efficacy of Sumatriptan and Naproxen Combination

Studies have shown that the combination of sumatriptan and naproxen is effective in treating migraine headaches, with a significant number of patients achieving pain-free status at 2 hours 4, 5, 7, 8. The combination has also been shown to be superior to either monotherapy, with a greater proportion of patients achieving sustained pain-free response 4, 5, 7.

Key Findings

Some key findings from the studies include:

• The combination of sumatriptan 85 mg or 50 mg and naproxen 500 mg was effective in treating migraine headaches, with a number needed to treat (NNT) of 3.1 for pain-free response at 2 hours when baseline pain was mild, and 4.9 when baseline pain was moderate or severe 4, 5
• Treating early, when pain was still mild, was significantly better than treating once pain was moderate or severe for pain-free responses at 2 hours and during the 24 hours post dose 4, 5
• Adverse events were mostly mild or moderate in severity and rarely led to withdrawal, but were more common with the combination than with placebo 4, 5, 8

Treatment Considerations

When considering the use of sumatriptan and naproxen combination for migraine treatment, it is essential to:

• Assess the patient's medical history and current medications to ensure safe use 4, 5, 6, 7, 8
• Monitor for adverse events, such as nasopharyngitis, hot flushes, and muscle tightness in adolescents, and dizziness, pain or pressure sensations, nausea, somnolence, dry mouth, dyspepsia, and paraesthesia in adults 8
• Consider the fixed-dose combination as a useful option for reducing pill burden and improving adherence in some patients 8