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HWN Suggests

Extra dry or up with a twist? A take on the ‘migraine cocktail’

You’re seeing a patient in the community emergency department with a primary headache disorder. Based on your history & physical examination skills, you have considered and ruled out all dangerous secondary headache causes such as intracranial hemorrhage, sentinel bleed, meningoencephalitis, abscess, tumor, temporal arteritis, hypertensive encephalopathy, acute angle closure glaucoma, etc. With many classes of treatments available, providers have typically used some form of a ‘migraine cocktail’ including IV prochlorperazine, IV ketorolac, IV diphenhydramine, IV dexamethasone, and/or IV normal saline.

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 The Migraine Cocktail: Emergency Department Management of Headaches

If the patient need a second round (or if their headache was terrible to begin with) I throw some IV mag at them. The evidence is weak at best, but it might help and is pretty safe, so why not. I usually re-dose metoclopramide at this point, but if their current or prior headaches are generally refractory, I often switch to haloperidol (2.5mg IV or IM).

 What a headache: Updates on Migraine Management

The Canadian Headache Society recommends 3 acute therapies that should be offered as first-line to all patients presenting with an acute migraine which are supported by a strong recommendation with high quality evidence. Ketorolac, Dopamine Antagonists (Metoclopramide or Prochlorperazine), Triptans.

 What’s the Best Migraine Drug(s) for Kids?

Prochlorperazine (0.15 mg/kg) is the most commonly studied and most effective intravenous abortive migraine therapy in children. Combination therapy with ketorolac (0.5 mg/kg) appears to improve success.

 Your Migraine Cocktail Didn’t Work? Shake it Up!

In this post, we will address adjunctive therapies when the first-line treatments haven’t broken your headache.

Articles of Interest

Haloperidol for Treatment of Headache in the Emergency Department

With a low side-effect profile, emergency physicians should consider the use of 2.5 mg IV haloperidol as a rapid and effective treatment for acute benign headache in adult emergency department patients aged 18 to 55 years old.

Part 1: Migraine Headache and Subarachnoid Hemorrhage

POUND mnemonic for diagnosis of migraine: Pulsatile quality, 4‐72 hOurs, Unilateral pain, Nausea, and Disabling intensity – 4 out of 5 features present gives a positive likelihood ratio of 24 for this headache to be a migraine (in a study based out of GP clinics); photophobia and phonophobia are also often present.

IV Magnesium for Acute Migraine Headache

Two previous studies found mixed results using magnesium. This new study found that IV magnesium may be an additional option. The authors didn't compare magnesium to more common treatments such as prochlorperazine or metoclopramide 20 mg (+/- ketorolac and diphenhydramine), which may limit its generalizability. However, magnesium's pain lowering effect was good regardless of comparator group.

Managing Migraine

Three classes of medication have emerged as first-line parenteral treatment of acute migraine: the antidopaminergics, the triptans, and nonsteroidal antiinflammatory drugs (Table). During the last 3 decades, compelling clinical evidence has emerged to support the use of antidopaminergics as monotherapy for acute migraine.

Managing migraine headaches in complicated patients

Management of chronic pain patients can be trying and demoralizing for emergency physicians because the underlying problem cannot be solved, and all avenues of treatment are flawed. Allowing the patient to suffer without appropriate justification is cruel. Delaying opioid administration during good faith efforts to identify alternative effective therapeutic agents is reasonable.

Migraine in the Emergency Department

There are varying levels of evidence associated with medications used for migraine in this setting. For example, there is relatively strong evidence that prochlorperazine, sumatriptan, metoclopramide and ketorolac are effective for migraine relief in the ED, whereas opioid medications, like morphine and tramadol, have less evidence for efficacy and may be associated with higher rates of return visits within a week of discharge from the ED.

Migraine Prophylaxis

American Academy of Neurology and American Headache Society level A drug options, starting dosages: Valproate/divalproex 250 mg q12. Metoprolol 25 mg q12. Propranolol 30 mg q8. Timolol 10 mg q12. Topiramate 25 mg QHS x1, then 25 mg q12.

Propofol for migraine in the emergency department: A pilot randomised controlled trial

Initial i.v. therapy with propofol, using a procedural sedation dose resulted in shorter times to discharge from the ED for patients presenting with migraine.

Severe Migraine: Options for Acute Therapy in the Emergency Department

Several options are still available. For a patient who wants to remain alert after treatment, parenteral ketorolac(-an effective analgesic that is usually nonsedating-is an excellent alternative. The recommended doses are 30 mg IV or 60 mg IM. Occasionally, magnesium sulfate(, 1000 mg IV, will abort a severe headache without sedating effects. Val- proate acid, 1000 mg IV, administered fairly rapidly over 15 minutes, is another alternative.

Resources

EMRA

Standard first-line migraine treatment options for moderate to severe pain include metoclopramide (10 mg IV), prochlorperazine (10 mg IV), chlorpromazine (12.5 mg IV), haloperidol (5 mg IV), or droperidol (2.5 mg IV or IM)

Science of Migraine

Migraine can be treated with acute and preventive treatment. These two strategies for treating migraine have distinct but complementary treatment goals.

BC Emergency Medicine Network

Opioids are not recommended for the treatment of acute migraine, and should only be considered as a last resort.