Acute and Preventive Management of Migraine Without Aura with Photophobia in Patients with Concurrent Labyrinthitis

Acute Treatment

Start acute therapy with a non‑steroidal anti‑inflammatory drug (ibuprofen, naproxen sodium, or aspirin) combined with a pro‑kinetic anti‑emetic, and limit use to ≤ 2 days per week to avoid medication‑overuse headache. [American Family Physician] 2
NSAIDs are the first‑line agents for most migraine attacks; the most consistently supported drugs are aspirin, ibuprofen, naproxen sodium, and the acetaminophen‑aspirin‑caffeine combination. [American Family Physician] 2
Acetaminophen alone is ineffective for acute migraine and should not be used. [American Family Physician] 2

If an attack does not respond to NSAIDs, migraine‑specific agents (triptans or di‑hydroergotamine) should be added. [American Family Physician] 2
Robust evidence supports oral and sub‑cutaneous sumatriptan, as well as naratriptan, rizatriptan, and zolmitriptan for acute migraine relief. [American Family Physician] 2
Absolute contraindications for triptans include uncontrolled hypertension, hemiplegic or basilar migraine, and any significant cardiac disease risk. [American Family Physician] 2
Intranasal di‑hydroergotamine has good evidence of efficacy and safety and can be considered when oral routes are unsuitable. [American Family Physician] 2

When early nausea or vomiting is prominent, a non‑oral route (nasal, sub‑cutaneous) should be selected for acute medication delivery. [American Family Physician] 2
Nausea should be treated with an anti‑emetic that possesses pro‑kinetic properties. [Journal of Neurology, Neurosurgery & Psychiatry] 3
Photophobia is a characteristic accompanying symptom of migraine without aura, occurring in the majority of patients. [Nature Reviews Neurology] 1

Avoid acute migraine medications that may exacerbate vertigo or nausea associated with labyrinthitis. [American Family Physician] 2
Prefer non‑oral administration (e.g., nasal spray or sub‑cutaneous injection) when labyrinthitis causes significant nausea. [American Family Physician] 2

Medication‑overuse headache is defined by regular use for > 3 months of non‑opioid analgesics on ≥ 15 days/month or triptans on ≥ 10 days/month. [Nature Reviews Neurology] 1

Begin preventive treatment when a patient experiences ≥ 2 migraine attacks per month with disability lasting ≥ 3 days, uses rescue medication > 2 times per week, or has failure/contraindications to acute therapies. [American Family Physician] 2

Propranolol, metoprolol, and topiramate are recommended as first‑line preventive agents. [Journal of Neurology, Neurosurgery & Psychiatry] 3
Caution: beta‑blockers, tricyclic antidepressants, and sodium valproate may promote weight gain. [Journal of Neurology, Neurosurgery & Psychiatry] 3
Topiramate can aid weight loss but may cause depression and cognitive slowing; it should be titrated slowly. [Journal of Neurology, Neurosurgery & Psychiatry] 3
Preventive drugs should be initiated at low doses and gradually increased to a tolerated therapeutic dose over approximately 3 months before efficacy is assessed. [Journal of Neurology, Neurosurgery & Psychiatry] 3

Limit caffeine intake, maintain regular meals, ensure adequate hydration, engage in regular exercise, and practice good sleep hygiene. [Journal of Neurology, Neurosurgery & Psychiatry] 3
Incorporate behavioral and stress‑management techniques such as yoga, cognitive‑behavioral therapy, and mindfulness meditation. [Journal of Neurology, Neurosurgery & Psychiatry] 3

Use a headache diary to record attack severity, frequency, duration, disability level, and response to treatment. [Nature Reviews Neurology] 1
Identify and document common migraine triggers (e.g., alcohol, caffeine, tyramine‑ or nitrate‑containing foods, stress, fatigue, strong odors, flickering lights). [American Family Physician] 2