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What inpatient treatments do we have for acute intractable migraine?

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We recommend the following combination treatment:

Normal saline (0.9% NaCl) 1 to 2 L by intravenous (IV) infusion over 2 to 4 hours. This can be repeated every 6 to 12 hours.

Ketorolac 30-mg IV bolus, which can be repeated every 6 hours. However, patients with coronary artery disease, uncontrolled hypertension, acute renal failure, or cerebrovascular disease should instead receive aceta­minophen 1,000 mg, naproxen sodium 550 mg, or aspirin 325 mg by mouth.

Prochlorperazine or metoclopramide 10-mg IV infusion. This can be repeated every 6 hours. However, to reduce the extrapyramidal adverse effects of these drugs, patients should first receive diphenhydramine 25- to 50-mg IV bolus, which can be repeated every 6 to 8 hours.

Sodium valproate 500 to 1,000 mg by IV infusion over 20 minutes. This can be repeated after 8 hours.

Dexamethasone 4-mg IV bolus every 6 hours, or 10-mg IV bolus once in 24 hours.

Magnesium sulfate 500 to 1,000 mg by IV infusion over 1 hour. This can be repeated every 6 to 12 hours.

If the migraine has not improved after 3 cycles of this regimen, a neurologic consultation should be considered. Other options include dihydroergotamine and occipital nerve blocks1 performed at the bedside.

GENERAL PRINCIPLES

Managing acute intractable migraine can be frustrating for both the practitioner and the patient. Some general principles are helpful.

Use a combination of drugs. Aborting a severe migraine attack often requires a combination of medications that work synergistically.

Use IV and intramuscular formulations rather than oral formulations: they are more rapidly absorbed, provide faster pain relief, and can be given when the nausea that often accompanies migraine precludes oral treatments.

Rule out secondary causes. The mnemonic SNOOP—systemic signs, neurologic signs, onset, older age, progression of existing headache disorder—is useful for assessing underlying causes.2 Any patient presenting with intractable migraine should also have a thorough neuro­logic examination.

Screening electrocardiography may be helpful, as the pretreatment QTc interval may direct the choice of intravenous treatment. If the patient has a prolonged QTc or is taking another drug that could prolong the QTc, certain medications, specifically dopamine receptor antagonists and diphenhydra­mine, should be avoided.

Ask the patient what has worked previously. A particular agent may have been effective in aborting the migraine; thus, a single dose of it could abort the headache, expediting discharge.

Establish if a triptan or ergot derivative has been used during the 24 hours before presentation, as repeated dosing within this interval is not recommended.3

Establish the baseline headache severity. Complete headache relief is difficult to achieve in a patient with chronic daily headache, and establishing a more realistic goal (eg, 50% relief) from the outset is useful.

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