How Do You Treat a Patient With Refractory Headache?

To Admit or Not to Admit?

A neurologist may have to decide whether to admit to the hospital a patient with chronic headache who is not doing well. First, the neurologist and patient should agree on a therapeutic target. Outpatient treatment works well if the patient is motivated and compliant and does not have confounding conditions. If the therapeutic target cannot be met through outpatient treatment, the neurologist should consider hospital admission. Insurance companies generally will cover three days of inpatient treatment, said Dr. Ward.

Neurologists have many options for inpatient treatment of refractory headache. Repetitive dihydroergotamine, known as the Raskin protocol, is highly effective if administered correctly. Dihydroergotamine should be given three times per day. “If you order it q. 8 h., the nurse will wake your patient up in the middle of the night, and waking up a patient with benign headaches is not a good idea,” said Dr. Ward. The dose must not be sufficient to cause nausea, because nauseating the patient can exacerbate headaches. “We usually premedicate with metoclopramide or prochlorperazine for nausea, but both of those drugs … also are good headache remedies.”

The Raskin protocol requires the withdrawal of other analgesics. The protocol typically lasts for three days, and most patients have good outcomes at this point. Extending the protocol to six or seven days may increase the number of patients with good outcomes. The success rate for the Raskin protocol is between 60% and 70%, said Dr. Ward. Patients who are pregnant or who have coronary artery disease should not receive dihydroergotamine, however.

Another option for inpatient treatment is IV chlorpromazine. The goal of this treatment is to induce a light sleep and maintain it for two or three days. The neurologist may start with a dose of 10 mg t.i.d. and monitor the patient’s response. The drug effectively suppresses narcotic withdrawal symptoms, so the neurologist may withdraw overused medications while the patient is asleep. Chlorpromazine may cause QT prolongation, so the patient should undergo cardiac monitoring. The drug also causes orthostatic hypotension, so patients should remain on bed rest and receive prophylaxis for deep venous thrombosis, said Dr. Ward.

IV valproate is an excellent choice if the patient has cardiac problems or bipolar disease, he added. The drug can be administered in a single dose of between 300 mg and 500 mg run in rapidly. “You can run in a whole loading dose in five or 10 minutes with virtually no side effects,” said Dr. Ward. Treatment can be administered b.i.d. or t.i.d. for two or three days. Pregnant patients should not receive valproate, however. Yet another option is IV magnesium, although the evidence for its efficacy is mostly anecdotal. A protocol of 1 to 2 g administered over 10 to 20 minutes, repeated several times per day, may be effective. It is advisable to monitor the patient’s serum magnesium levels to ensure that they do not become excessive. Magnesium may adversely affect fetal bone development, so neurologists should exercise caution when considering the drug for a pregnant patient. IV magnesium is “an excellent choice for hemiplegic migraine,” said Dr. Ward.

If the patient’s occipital nerves are tender, occipital nerve blockade may relieve pain. IV ketorolac, in 30-mg doses t.i.d. or q.i.d., may alleviate breakthrough headaches. Lidocaine patches can reduce back or neck pain for as long as 12 hours daily.

Abruptly withdrawing butalbital entails a risk of seizures and delirium. Neurologists may wish to administer phenobarbital in its place, as a single bedtime dose, while they are tapering or stopping butalbital. A 30-mg dose of phenobarbital may be substituted for every 100 mg of butalbital, said Dr. Ward.

Suggested Reading

Ford RG, Ford KT. Continuous intravenous dihydroergotamine in the treatment of intractable headache. Headache. 1997;37(3):129-136.

Lai TH, Wang SJ. Update of inpatient treatment for refractory chronic daily headache. Curr Pain Headache Rep. 2016;20(1):5.

Levin M. Opioids in headache. Headache. 2014;54(1):12-21.

Lipton RB, Silberstein SD, Saper JR, et al. Why headache treatment fails. Neurology. 2003;60(7):1064-1070.