Migraine with Aura When Analgesics or NSAIDs Fail to Reduce Headache
Clinical Scenario
This protocol applies to patients with migraine with aura experiencing moderate to severe attacks in which treatment with analgesics or non-steroidal anti-inflammatory drugs (NSAIDs) does not achieve adequate headache reduction within 2 hours of administration.
Previous Treatment & Failure Condition
First-line management of migraine attacks — analgesics or NSAIDs — failed to meet its primary target:
Reduction of headache 2 hours after taking the medication was not achieved.
This unmet goal is the trigger for escalation to the next treatment step.
Next-Step Approach
For moderate to severe migraine attacks that do not respond adequately to analgesics or NSAIDs, a targeted class of serotonin receptor agonists is indicated. There are specific timing considerations for patients who experience aura that must be observed before this therapy is initiated.
The therapeutic goal at this stage is:
Pain-free at 2 hours after administration
References
DOI: 10.1177/2514183X1882337
- The serotonin (5-HT)1B/1D-receptor agonists (so-called triptans) almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan and zolmitriptan are the therapy of first choice in moderate and severe migraine attacks which are not or only insufficiently responsive to therapy with analgesics or non-steroidal anti-inflammatory drugs (NSAIDs).
- Sumatriptan subcutaneous injection (6 mg) is the most effective therapy of acute migraine attacks.
- For safety reasons, patients who suffer migraine with aura should not take a triptan until the aura has abated and the headache started.
- Triptans are more effective than analgesics or NSAIDs for the endpoint 'pain-free after 2 h' in most randomized studies.
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