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