Neurology Question 79

Answer & Critique

Correct Answer: E

Educational Objective: Treat acute refractory migraine.

Key Point

Self-administered subcutaneous sumatriptan is appropriate as therapy for migraine without aura in patients not responding to NSAIDs or oral triptans, especially those with vomiting.

The patient should be treated with subcutaneous sumatriptan for migraine without aura. She no longer responds to NSAIDs and oral triptans. The headaches are associated with emesis, and she is awakening with attacks. Migraine episodes have been so severe that she has visited an urgent care facility recently for parenteral treatment of refractory migraine. Self-administered injectable migraine medications would be of value for this patient. Although nasal spray options exist for several acute medications, they are less potent than their injectable counterparts. According to guidelines, no first-line agent for acute migraine treatment is available in suppository form.

Neither butalbital compounds nor opioids (such as hydrocodone) are recommended as first-line treatments of recurrent headache disorders. Little evidence of benefit in acute migraine exists for either class of drugs, and both contribute to an increased future risk of transformation into chronic migraine, compared with first-line agents.

Evidence supports the use of naproxen in the management of acute migraine, and the drug is listed by evidence-based guidelines as first-line therapy. In the setting of migraine that occurs upon awakening or with vomiting, however, it is unlikely to be beneficial, especially in a patient who has not responded to another NSAID or oral triptan.

The orally dissolvable versions of rizatriptan and zolmitriptan require gastrointestinal absorption and thus should not be used in the setting of migraine with vomiting.


Kelley NE, Tepper DE. Rescue therapy for acute migraine, part 1: triptans, dihydroergotamine, and magnesium. Headache. 2012 Jan;52(1):114-28. PMID: 22211870

This content was last updated in August 2015.

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