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    Migraine – Management

    Neurological

    Last Updated Aug 12, 2019
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    Context

    • Treatment of severe migraine in the emergency department (ED) should involve intravenous (IV) fluid hydration, and administration of non-opioid IV medications and antiemetics.
    • Opioids are not recommended for the treatment of acute migraine, and should only be considered as a last resort.

    Recommended Treatment

    Abortive Treatment

     

    IV fluids:

    • 1 L bolus of normal saline solution.

    NSAIDs:

    • Ketorolac is recommended for use in the ED given its parenteral formulation.
      • 60 mg intramuscular dose, or 10 – 30 mg intramuscular (IM) or IV doses every 6 hours (maximum daily dose of 120 mg).

    Acetaminophen:

    • Frequently taken by patients before presentation to the ED.
    • Can be used as a monotherapy only for patients who have not already taken it in the preceding 4 hours and have a minor migraine.

    Antidopaminergics/Antiemetics (give slowly to avoid akathesia)

    • Metoclopramide (10 mg IV), or
    • Chlorpromazine (ranging from 0.1 mg/kg IV to a total dose of 25 mg IV), or
    • Prochlorperazine (10 mg IV or IM)
    • Adjuvant diphenhydramine (5 to 25 mg IV every hour up to two doses) reduces the occurrence of akathisia that is commonly associated with metoclopramide, chlorpromazine, and prochlorperazine.

    Triptans (serotonin receptor agonists):

    • Subcutaneous sumatriptan has been shown to be effective in acute migraine treatment and has the fastest onset of action compared to oral or intranasal formulations.
      • Less effective than antidopaminergics
      • 6 mg initial dose
      • Dose may be repeated once, if needed, after one hour
      • Maximum dose of 12 mg per 24 hours
      • Unpleasant adverse effects (number needed to harm1⁄44), includes chest symptoms, flushing, and worsening of the headache.
      • Two thirds of patients who receive sumatriptan report recurrence of headache within 24 hours.

    Ergots:

    • Parenteral dihydroergotamine (1 mg IV) administered with an antiemetic (ie. 10 mg IV metoclopramide) is shown to be effective in acute migraine treatment.
    • Mostly been supplanted by sumatriptan.
    • The effectiveness of ergotamine has not been demonstrated.

    Adjunctive dexamethasone:

    • When added to standard acute migraine therapy, parenteral dexamethasone treatment (10 mg IV or IM) has been shown to reduce the risk of early headache reoccurrence 24 to 72 hours after initial treatment.

    Opiates and barbiturates:

    • Opioids generally are not as effective as migraine-specific medications for acute migraine treatment, and its use is complicated by the risk of tolerance, dependence, addiction, and overdose.
    • There is no evidence supporting the efficacy of barbiturates (ie. butalbital-containing compounds) for acute migraine treatment.
    • Opioid and butalbital use is associated with increased risk for developing chronic migraine and medication overuse headache.

    How does acute treatment change if the patient is already on prophylactic treatment?

    • Acute migraine treatment regimen should be adjusted to prevent exceeding the maximum dosage of drugs used for prophylactic treatment.

     

    Other treatments

    • Antihistamines such as diphenhydramine and hydroxyzine probably are not efficacious in acute migraine.
    • Ketamine and propofol work acutely, but it is unclear what happens to the headache after the medication wears off.
    • Magnesium has not consistently shown benefit.
    • Parenteral ondansetron and other serotonin-receptor antagonists have not been well studied in acute migraine.

    Criteria For Hospital Admission

    • In cases of intractable vomiting, inpatient treatment with IV fluids and antiemetics may be necessary. In rare cases, status migrainosus (headache ≥ 72 hours ) may require hospitalization for hydration and non-opioid IV medications.

    Criteria For Close Observation And/or Consult

    • If patient exhibits “red flag” features:
      • The “first or worst” headache.
      • Recent significant change in the pattern, frequency, or severity of headaches.
      • New or unexplained neurologic symptoms or signs.
      • Headache always on the same side.
      • Headaches not responding to treatment.
      • New-onset headaches after age 50 years.
      • New-onset headaches in patients with cancer or HIV infection.
      • Associated symptoms and signs such as fever, stiff neck, papilledema, cognitive impairment, or personality change.

    Criteria For Safe Discharge Home

    • Most patients with migraine without severe pain, vomiting, or dehydration.
    • If patient exhibits no “red flag” features (see above).

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