Which medication is best for initial acute treatment of a migraine in this patient?

• A. Topiramate
• B. Gabapentin
• C. Propranolol
• D. Sumatriptan

Answer: (D)

For an acute migraine attack, you want a fast-acting therapy that directly aborts the current episode. Sumatriptan fits that role because it’s a selective 5-HT1B/1D receptor agonist that constricts cranial blood vessels and reduces the release of inflammatory mediators like CGRP in the trigeminovascular system. This combination helps rapidly lessen headache intensity and accompanying symptoms when taken at onset, making it the preferred choice for initial acute treatment.

Preventive medications such as topiramate, gabapentin, or propranolol are aimed at reducing how often migraines occur over time; they aren’t designed to stop an ongoing attack quickly. So they’re not the best option for the immediate relief needed during an acute episode.

Keep in mind that triptans are best avoided in patients with certain cardiovascular risks because of vasoconstriction. If contraindicated, alternatives like NSAIDs or non-vasoconstrictive agents (such as lasmiditan or gepants) can be used. Also, sumatriptan formulations (oral, nasal, or injectable) offer options to match the patient’s symptoms and tolerability.