Migraine with Brainstem Aura When Triptan Plus NSAID Combination Has Not Achieved Pain Freedom

This protocol applies to patients presenting with acute migraine with brainstem aura in whom prior oral acute therapy has failed to reach the expected treatment goals — specifically, freedom from pain and prevention of headache recurrence within the target window.

Prior Treatment Line — Goals Not Met

The preceding step used a combination of a triptan with a long-acting NSAID (Naproxen). That line targets freedom from pain within 2 hours of administration and prevention of headache recurrence within 2–24 hours. When both of these goals are not achieved, escalation to the current protocol is indicated.

Next-Step Approach

The structured protocol for this situation involves emergency parenteral therapy — medications administered via intravenous or subcutaneous route — selected according to specific clinical criteria and the clinical picture at presentation. The complete agent selection, clinical decision algorithm, and management of prolonged or refractory attacks are detailed in the full protocol.

Treatment Goals

The clinical targets for this protocol are reduction in headache intensity and reduction of recurrent headache.

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References

DOI: 10.1177/2514183X1882337

The treatment of first choice is the intravenous administration of 1000 mg ASA with or without metoclopramide.

If there are no contraindications, sumatriptan 6 mg can also be given subcutaneously.

The following drugs can be used for intravenous injections: ASA, metoclopramide (and other dopamine-antagonists), metamizole, sumatriptan and steroids.

Based on expert consensus, therapy of a status migrainosus is recommended with a single administration of 50–100 mg prednisone or 4–8 mg dexamethasone.

The data indicate a reduction in headache intensity and a reduction of recurrent headache.

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