-Status migrainosus (migraine lasting >72 hours) is one of the most common reasons patients with migraine seek emergency medical care
-Before coming to the ED, many patients have already tried at least 1 rescue medication without adequate relief
-Migraine tends to become more difficult to treat as it becomes more prolonged
-Remember to obtain a thorough headache history to determine if the presentation is true status migrainosus, or if it is a secondary headache
Sample Algorithm for Management of Status Migrainosus in the Emergency Department
IV Fluids - at least 1L NS
-important for patients with poor PO intake, significant nausea/vomiting, and to aid in renal clearance of medications
Ketorolac 30mg IV + metoclopramide 10mg IV +/- benadryl 25mg PO (if can tolerate PO) q8h prn
-can use prochlorperazine 10mg IV in place of metoclopramide
-caution using IV benadryl - can be very sedating, but is helpful for akathisia which is common after using dopaminergic agents (like reglan and compazine)
-should repeat this at least 2-3 times
Add Magnesium Sulfate 1000mg IV run slowly in between, can use up to 2000mg (in one infusion, or can do 1g at a time)
If no relief:
Valproic acid 1000mg IV in 50cc NS run over 15 min OR levetiracetam 1000mg IV in 50cc NS over 15 min
-must get pregnancy test in woman of childbearing age prior to administering valproic acid
-if helpful, can send out on a taper of 500mg BID x 3 days, then 250mg BID x 3 days, then 250mg daily x 3 days then stop
Can also consider dexamethasone 4mg, 8mg, or 10mg IVP prior to discharge
-mixed data, but may reduce risk of recurrence, and can aid in management of medication overuse headache
If the headache is lasting 1-2 days and the patient has not used triptan:
-Can try sumatriptan 6mg subcutaneous injection x 1 in the ER
AVOID OPIATES!
Things to Remember
-Avoid ketorolac/NSAIDS if there is bleeding/SAH, poor renal function, or allergy
-Avoid metoclopramide/prochlorperazine if there is a history of significant dystonic reactions in the past (trial zofran 8mg IV)
-Avoid valproic acid in patients with hepatic disease
-Avoid levetiracetam in patients with complex/significant mood disorder or depression
-Avoid triptans in patients with history of stroke or CAD
If still no relief:
-Consider nerve blocks, headache medicine consult, admission for IV DHE
Management of Medication Overuse Headache in the Emergency Room
-Can use the same algorithm as above, consider using steroids to prevent recurrence
-THE PATIENT MUST STOP THE OFFENDING AGENT (ie acetaminophen, excedrin, ibuprofen/naproxen)
-If the patient is overusing fioricet, the patient likely needs to taper as it is not safe to abruptly stop (can lead to withdrawal seizures depending on number of pills being consumed daily)
-On discharge, can send home with prednisone taper 60mg daily taper down by 10mg daily until off as a bridge
Other options: dexamethasone 12mg-8mg-4mg taper, celebrex 200mg BID for 5-7 days, nabumetone 500mg BID for 5 days, depakote taper (as above)