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)

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