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.
- 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)
- 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.
- 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.
- 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