A Neurologist’s Guide to Acute Migraine Therapy in the Emergency Room

Abstract

Migraine is a common reason for visits to the emergency room. Attacks that lead patients to come to the emergency room are often more severe, refractory to home rescue medication, and have been going on for longer. All of these features make these attacks more challenging to treat. The purpose of this article is to review available evidence pertinent to the treatment of acute migraine in adults in the emergency department setting in order to provide neurologists with a rational approach to management. Drug classes and agents reviewed include opioids, dopamine receptor antagonists, triptans, nonsteroidal anti-inflammatory drugs, corticosteroids, and sodium valproate.

In vivo imaging reveals that pregabalin inhibits cortical spreading depression and propagation to subcortical brain structures

“…Although a number of preventative and abortive treatments are available, not all migraines are effectively treated, and hospitalization can be necessary for prolonged migraine attacks (2,17). Gabapentinoids (gabapentin and pregabalin) are small-molecule drugs used clinically in the treatment of neuropathic pain and partial seizures.…”

Pediatric Inpatient Headache Therapy: What is Available

“…Patients are pre‐medicated with prochlorperazine (0.13‐0.15 mg/kg) 30 minutes prior to the DHE dosing, trying to prevent frequent nausea and vomiting that occurs with treatment. Prochlorperazine was preferred to the use of metoclopramide due to multiple studies showing higher efficacy than the metoclopramide as well as decreased rate of rebound after discharge from the emergency room when prochlorperazine is used compared to the metoclopramide . A dose of DHE of 0.5‐1 mg (depending on age and weight) is given every 8 hours until headache freedom plus one extra dose when the headache stops.…”

“…Prochlorperazine was preferred to the use of metoclopramide due to multiple studies showing higher efficacy than the metoclopramide as well as decreased rate of rebound after discharge from the emergency room when prochlorperazine is used compared to the metoclopramide. 9 A dose of DHE of 0.5-1 mg (depending on age and weight) is given every 8 hours until headache freedom plus one extra dose when the headache stops. Prochlorperazine is stopped after three doses to prevent any extrapyramidal syndrome and is replaced by a different antiemetic such as ondansetron.…”

Headache in the Emergency Room

“…A migraine that lasts more than 24 hours is typically more difficult to treat and after 48 hours the headache is described as status migrainosus. 48 The main strategy to treating migraines in the ER involves providing hydration and adequate pain control as well as treating the other associated features like nausea, for example. 48 Medications used to treat acute migraine attacks include both oral and IV medications.…”

“…48 The main strategy to treating migraines in the ER involves providing hydration and adequate pain control as well as treating the other associated features like nausea, for example. 48 Medications used to treat acute migraine attacks include both oral and IV medications. Unfortunately, no set protocol exists; and medications are generally prescribed based on physician preference or comfort level.…”