What are emergency treatment options for severe migraine?
Five million visits to US Emergency Departments annually are due to patients with migraine.
Intravenous hydration is important for those who have been vomiting.
The Canadian Headache Society systemic review strongly recommends use of the following:
- intravenous (IV) prochlorperazine 10 mg (which may be given with diphenhydramine 25 mg IV to prevent extrapyramidal side effects; diphenhydramine can also be given with metoclopramide);
- metoclopramide 10 mg IV;
- sumatriptan 4 to 6 mg SC (not used first line if another triptan has been taken in the past 24 hours); and
- ketorolac intramuscularly (IM) and IV 60 mg
- Dihydroergotamine 0.5 mg IV with an antiemetic is a reasonable first-line option in the appropriate patient who has not had a triptan within 24 hours.
- Meperidine 75 to 100 mg IM is weakly recommended.
The Society strongly recommends against the use of dexamethasone for the acute treatment of migraine pain.
Sources
Evans RW, Tepper SJ, Shapiro RE, et al.: The FDA alert on serotonin syndrome with use of triptans combined with selective serotonin reuptake inhibitors or selective serotonin-norepinephrine reuptake inhibitors: American Headache Society position paper. Headache 50:1089-1099, 2010.
