Pathway for the Treatment of Migraine in the Emergency Department

Kazi F, Manyapu M, Fakherddine M, Mekuria K, Friedman BW. Second-line interventions for migraine in the emergency department: A narrative review. Headache. 2021 Nov;61(10):1467-1474. doi: 10.1111/head.14239. Epub 2021 Nov 22. PMID: 34806767.

Emergency Department Treatment

  • If pain is severe or if there is nausea, liberal IV fluid replacement
  • Chlorpromazine and prochlorperazine are first-line agents, particularly if there is nausea
  • If further treatment is needed, DHE or subcutaneous sumatriptan, followed by parenteral NSAIDs (IV aspirin if available)
  • IV sodium valproate, but use with caution in women of child-bearing age ​(Goadsby). UCSF protocol 250 mg q 8 hours over 4 days. Infusion is over 60 min. Retrospective study at UCSF of patients with refractory chronic migraine showed 9 of 13 patients (69%) improved.

Prochlorperazine (Compazine)

  • Typical adult dosing is 10 mg given IV or IM (2 mL or prochlorperazine edisylate Injection, USP 5 mg/mL)
  • Also 25 mg suppository

 IV prochlorperazine with diphenhydramine: 500-mL bolus of IV saline solution and 10 mg prochlorperazine with 12.5 mg diphenhydramine (Benadryl) IV (more effective than sumatriptan SQ 6 mg)

Dihydroergotamine (DHE)
  • Typical dose: 0.5 mg or 1 mg DHE either IV or IM; can be repeated to a maximum of 3 mg in 24 hours
  • Nausea is common side effect with IV and pretreatment with an antiemetic is needed
  • When DHE is administered IM or as nasal spray, nausea is not as prominent and pretreatment is not always necessary.
  • Contraindications: pregnancy, history of cerebrovascular disease, uncontrolled hypertension.

Ketorolac

  • Contraindicated in active peptic ulcer disease
  • Caution in renal insufficiency (may cause acute renal failure) and severe asthma
  • Ketorolac 30 mg IV is inferior to prochlorperazine 10 mg IV.

Sodium Valproate

  • Single IV load 300 to 1200 mg; no clear dose-related pattern in improved response.
  • Urine pregnancy test before giving this medication to a woman of child-bearing age
  • Contraindicated in liver disease and urea cycle defects

Dexamethasone

Contraindications: uncontrolled diabetes, allergic reactions

SIG: Dexamethasone 1 mg tab. 5 tabs PO BID x2 days, 4 tabs BID x2 days, 3 tabs BID x2 days, 2 tabs BID x2 days, 1 tab PO BID x2 days, stop. # tabs: 60. No refill

Patient instructions:

DEXAMETHASONE (Decadron) steroids can help break headache cycle. 
- To protect the stomach during the 10 days, take PRILOSEC 20 mg every morning, 30 minutes before food (it's an over the counter medicine) 
- 10 day taper (meaning you take a high dose at the beginning and slowly decrease it over 10 days) 
- ALWAYS take with food
- Take in morning and at lunch. Do not take it after lunch, it can cause insomnia. 
- No advil, ibuprofen, motrin, aleve, naproxen or other anti-inflammatory drugs during the steroids 
- Avoid alcohol 
 
Some side effects to watch for:
-Insomnia, blurred vision, confusion, dizziness
-Blood pressure change, heart rate change, high blood sugar
-Nausea, vomiting, upset stomach, acid reflux, increased appetite
-Risk of infection, water retention / swelling, mood change / anxiety
-Thin skin, bruising, bleeding, rash, acne, sweating if used over a long time for months
-Muscle atrophy (shrinking) if used over a long time for months
-Weight gain / increase amount of fat in the body  if used over a long time for months
**Side effects would be temporary since you will stop the medication after 10 days.