Check first

• Is it his usual migraine? Ask about the same side, character, aura, nausea, photophobia and phonophobia. Right-sided headache is compatible with migraine, but he should be confirmed as a migraineur by history.
• Red flags (SNNOOP-type): thunderclap or worst-ever onset, fever or neck stiffness, new neurological deficit, papilledema, trauma, a change from his usual pattern, age over 50 at onset (not applicable here), immunosuppression, and positional or Valsalva-triggered pain.
• Unilateral headache with autonomic features, such as red eye, tearing, ptosis or restlessness, suggests cluster headache. Painful eye, halos or visual blurring suggests acute angle-closure glaucoma. Neck pain or Horner's syndrome suggests carotid dissection.
• Contraindications to triptans: coronary disease, uncontrolled hypertension, prior stroke or TIA, hemiplegic or brainstem aura, and recent ergot use.

Suggested regimen if it is typical migraine

• Take the medicine early. NSAIDs and triptans work best when given at the start of the attack.
• A triptan plus an NSAID is more effective than either alone.
• If symptoms return or have not eased within 60 minutes, increase the dose or switch class next time. Repeating the same triptan at 2 hours is safe but ineffective.
• If he is a triptan non-responder or has a contraindication, gepants (rimegepant, ubrogepant) or lasmiditan are options.
• Avoid opioids. They worsen outcomes and can lead to medication-overuse headache.
• Limit acute medication to under 10 days a month for triptans and combination analgesics, and under 15 days a month for simple analgesics.
• Check for gastric ulcer or GI bleeding risk, renal disease and asthma before giving an NSAID.
• If he has frequent attacks, consider preventive therapy such as propranolol, amitriptyline, topiramate or candesartan.

Sources

• Harrison's Principles of Internal Medicine 22E, "Acute Attack Therapies for Migraine": the five effective drug classes are NSAIDs, triptans, gepants, ditans and dopamine antagonists. Mild attacks can be managed with oral agents, and the dose should be adequate and given early.
• Bradley and Daroff's Neurology in Clinical Practice, "Symptomatic Treatment": combining an NSAID, a triptan or ergot, and a dopamine-antagonist antiemetic targets several mechanisms of an acute attack.
• Tintinalli's Emergency Medicine: triptans are first-line in the outpatient setting. Opioids should not be used for primary headaches.
• Goodman & Gilman's Pharmacological Basis of Therapeutics, "5HT 1B/D Receptor Agonists: The Triptans": a sumatriptan/naproxen fixed-dose combination exists.

Recent evidence check