Practice corner: clinical practice guidelines and handheld computers.

A 22 year old woman comes to your office for the first time complaining of a 1 day history of a “terrible headache.” She describes a throbbing pain on the left side of her head. She works as a mail carrier, and the pain became worse this morning with walking. The patient describes accompanying anorexia, nausea, and several episodes of vomiting. She reports sensitivity to bright lights and loud sounds and tells you, “I just want to crawl into a dark corner until it goes away.” She has taken ibuprofen, 400 mg every 6 hours, without relief. The patient reports no auras, facial pain, nasal discharge, tearing, fever, neck pain or stiffness, weakness, dizziness, numbness or tingling in the extremities, or change in vision. The patient has never had a headache like this before and has no significant medical history. She uses no medications apart from acetaminophen. Her older sister, who has had headaches of this type for several years, accompanies the patient. You decide that your patient is having a migraine and that you will probably prescribe a triptan. However, you want to know what forms are currently recommended in what doses, given the patient’s severe nausea. You formulate the question: in a patient with migraine and severe nausea, what are the current best treatment options to decrease acute symptoms?