A 32-year-old woman requests Migralev Yellow (paracetamol 500 mg and codeine) for migraines. She is a CYP2D6 extensive metabolizer. What is the most appropriate action?

• A. Recommend sumatriptan 50mg tablets with appropriate counselling
• B. Prescribe a higher dose of codeine
• C. Advise stopping migraine treatment altogether
• D. Prescribe more paracetamol only

Answer: (A)

The main issue is choosing an acute migraine treatment that provides reliable relief while minimizing opioid exposure, taking into account how codeine is metabolized by CYP2D6. Codeine is a prodrug that is converted to morphine by CYP2D6. In an extensive metabolizer, this conversion happens efficiently, which can give analgesia but also raises the risk of opioid-related side effects and dependence. For migraine attacks, using a paracetamol-codeine combination is not ideal because the opioid component adds safety concerns and offers no clear advantage over migraine-specific therapies.

Sumatriptan, a triptan, is a targeted treatment for acute migraine with strong efficacy and a favorable safety profile for many patients. It works directly on serotonin receptors to constrict cranial blood vessels and dampen inflammatory neuropeptide release, addressing the underlying migraine process rather than simply masking pain. Starting sumatriptan at the onset of an attack and providing appropriate counselling about dosing, potential side effects (such as chest tightness, dizziness, or paresthesias), and contraindications (notably certain cardiovascular risks) makes it a more effective and safer option than increasing opioid use or sticking with the combination product.

So the best action is to prescribe sumatriptan 50 mg with counselling. The other options either heighten opioid exposure without adding migraine-specific benefit or fail to address the acute attack appropriately.