Headache Treatments
Michael A. Rogawski, M.D., Ph.D.
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  • Testing Routine Blood Migraine
  • Acute Migraine Treatment (status migrainosus), Triptans, NSAIDs
  • CGRP Antibodies and Gepants
  • Preventative Migraine Treatments
  • NSAID
  • Headache Types
  • Emergency Department Treatment
  • Tension Type Headache
  • Indomethacin Responsive Headaches
  • Children and Adolescents
  • Medication Overuse Headache
  • IV Infusion Protocols
  • Posttraumatic Headache
  • Migraine Mimics
  • High and Low Pressure Headache
  • Devices
  • Lawrence Robbins: Advanced Headache Therapy
  • Hemiplegic Migraine
  • Cluster Headache Treatment
  • Headache Tracking
  • Sleep - Insomnia
  • Triggers/Caffeine
  • Depression Screening PHQ-2 and PHQ-9
  • Publications
  • Menstruation, Pregnancy and Breastfeeding
  • Contraception - Birth Control
  • Menopause - Menopausal Vasomotor Symptoms
  • Butterbur
  • Prodrome and Aura
  • Tinnitus
  • Neck Pain; Spinal Anatomy & Dermtomes
  • Behavioral Therapy
  • Exercise
  • Magnesium, Nutritional Supplements and Alternative
  • Hypertension Guidlines
  • MIDAS (Migraine Disability Assessment) and ASC-12
  • Botox
  • Vestibular Migraine
  • Nerve Blocks
  • Cannabinoids
  • Deprescribing/ Withdrawing Medications
  • Epilepsy/Seizure Drugs in Development
  • Occipital Epilepsy
  • Chronic Pain / Back Pain
  • HIT-6 Headache Impact Test
  • Thunderclap Headache
  • Cerebral Vascular Anatomy
  • Nonpharmacological Measures
  • SphenoCath

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