First-Line Drugs for Migraine

Acute (Abortive) Treatment

1. Mild-to-Moderate Attacks - NSAIDs and Analgesics

"If the headaches are mild, the patient may already have learned that aspirin, acetaminophen, or another NSAID will suffice to control the pain and these are considered first-line therapy." - Adams and Victor's Principles of Neurology, 12th Ed.

2. Moderate-to-Severe Attacks - Triptans (Serotonin Agonists) ★ Main First-Line

"These agents rapidly and effectively abort or markedly reduce the severity of migraine headaches in about 70% of patients and are first-line agents in the treatment of acute migraine." - Lippincott Pharmacology

3. Antiemetics (often given with analgesics or triptans)

4. Severe/Refractory Attacks - Ergot Alkaloids

• Dihydroergotamine (DHE): 1 mg IV - efficacy similar to sumatriptan; pretreat with antiemetic. Contraindicated in pregnancy, ischemic heart disease, uncontrolled hypertension.
• Ergotamine: Sublingual; use early. Limited by rebound headache risk and vasoconstrictor side effects.

5. Newer Agents (CGRP-Based)

• Gepants (CGRP receptor antagonists): e.g., ubrogepant, rimegepant - an emerging first-line option, especially in patients with cardiovascular contraindications to triptans.
• Ditans (5-HT1F agonists): e.g., lasmiditan - effective without vasoconstriction; useful in cardiovascular-risk patients.

Preventive (Prophylactic) Therapy

Key Clinical Pearls

• Treat early - triptans and ergots are most effective at attack onset or during aura
• Medication overuse headache: NSAIDs, triptans, and especially opioids can all cause rebound (medication overuse) headache if used >10-15 days/month
• Sumatriptan + naproxen combination is FDA-approved and more effective than either alone
• Triptans are ineffective during aura for prevention but are safe to take then
• If one triptan fails, try another - response is individual

Naproxen Dosage for Migraine

Acute Migraine Attack

• The standard acute dose is 500 mg PO at onset of headache
• May be repeated if needed, but limit total daily use to avoid rebound headache

General Dosing Range (from Harrison's & Rosen's)

• Oral: 220-550 mg twice daily (bid)
• For acute attack: 500 mg as a single dose (Rosen's Emergency Medicine)
• Brand names: Aleve (OTC), Anaprox, Naprosyn

Important Notes

• GI upset is the main side effect - take with food or milk
• Risk of medication overuse headache (MOH) if used >10-15 days/month
• Avoid in: peptic ulcer disease, renal insufficiency, third trimester of pregnancy, hypersensitivity to NSAIDs
• Sumatriptan + naproxen sodium (85 mg/500 mg) is an FDA-approved combination product (Treximet) shown to be more effective than either drug alone for moderate-to-severe migraine

"Naproxen sodium 500 mg PO" - Rosen's Emergency Medicine, Table 39.1 "Naproxen 220-550 mg PO bid" - Harrison's Principles of Internal Medicine, 22nd Ed.

Corrected FNAC Report

Grammar Corrections Made

Diagnostic Discussion

Key Cytological Findings & Their Significance

Why TB Cannot Be Ruled Out

• TB lymphadenitis can present as a cold abscess - soft, fluctuant, non-tender - but can also be tender
• The classic finding of epithelioid granulomas with Langerhans giant cells may be completely obscured when there is extensive caseation/necrosis
• ZN stain has low sensitivity (~30%) for Mycobacterium tuberculosis in FNAC specimens
• Supraclavicular lymphadenopathy is a well-known site for tuberculous lymphadenitis in endemic regions
• CBNAAT (GeneXpert MTB/RIF) is the gold standard next step - sensitivity ~80-90% on lymph node aspirate, also detects rifampicin resistance

Differential Diagnosis

1. Pyogenic abscess - most likely based on cytology (neutrophil-dominant, acute onset 10 days)
2. Tuberculous lymphadenitis - must be excluded given endemic setting and necrotic pattern
3. Non-tuberculous mycobacterial (NTM) infection - less common
4. Metastatic carcinoma with necrosis - excluded by absence of malignant cells

Recommended Workup

• CBNAAT/GeneXpert on aspirate (as advised) - priority
• Culture and sensitivity if pyogenic organism suspected
• Chest X-ray for pulmonary TB
• Mantoux test / IGRA (e.g., QuantiFERON)
• If CBNAAT negative and clinical suspicion remains high - excision biopsy for histopathology

CBNAAT Sample Sending Guide - Pus / Necrotic Abscess

What Vial/Container to Use

You do NOT directly put pus into the cartridge. The pus goes into the SR bottle first (or a sterile container sent to lab).

Step-by-Step Procedure

At the Bedside (Your Job - Sample Collection)

1. Aspirate the pus using sterile needle and syringe (use aseptic technique)
2. Collect a minimum of 1 mL of pus (ideally 2-4 mL for best yield)
3. Transfer the aspirated pus into a sterile screw-cap falcon tube (do NOT use swab - aspirate is always superior)
4. If thick/necrotic pus - add 0.7 mL of sterile PBS (phosphate-buffered saline) to homogenize if available, or send as is
5. Label the tube with: Patient name, ID, date, specimen type ("pus - right supraclavicular abscess")
6. Place tube in a sealed biohazard bag
7. Transport to lab at 2-8°C as soon as possible (within 1-2 hours ideally)

At the Lab (Lab Technician's Job)

• Add Sample Reagent (SR) in 2:1 ratio → 2 parts SR : 1 part pus
  • Example: 1 mL pus + 2 mL SR
• Secure the lid, shake vigorously 10-20 times
• Incubate 15 minutes at room temperature (20-30°C)
• At 5-10 min mark - shake again 10-20 times
• Transfer 2 mL of processed sample into the GeneXpert cartridge
• Load cartridge into GeneXpert instrument
• Result in ~100 minutes

• Add 2 mL PBS, homogenize/vortex
• Take 0.7 mL of homogenized specimen
• Add 1.4 mL of Sample Reagent (2:1 ratio - SR:sample)
• Mix and incubate as above
• Load into cartridge

Key Points to Remember

Expected Yield for Pus/Abscess

What to Write on Lab Request Form

• Specimen: Pus aspirate - right supraclavicular abscess
• Test requested: CBNAAT (GeneXpert MTB/RIF)
• Clinical history: Painful swelling 10 days, FNAC showing necrotic abscess, ZN negative, TB cannot be ruled out
• Concurrent tests: Culture & sensitivity (send a separate aliquot in sterile container)