Emergency Department Migraine Headache Care

Aka: Emergency Department Migraine Headache Care, Migraine Headache Care in the Emergency Department

1. See Also
   1. Headache Evaluation
   2. Migraine Headache
   3. Migraine Headache Management
   4. Migraine Headache Management in Children
   5. Migraine Abortive Management
   6. Migraine Prophylaxis
   7. Headache Red Flags
   8. Headache General Measures
   9. Migraine Medications in Pregnancy
   10. Migraine Medications in Breast Feeding
   11. Headache in Pregnancy
2. Indications
   1. Migraine Headache refractory to home care (6-72 hours)
3. Preparations: Antiemetics
   1. Dopamine-antagonists are preferred
      1. Prochlorperazine (Compazine) with IV hydration
         1. Often effective for aborting intractable Headache
         2. Adults: 10 mg IV
         3. Child: 0.15 mg/kg IV
      2. Metoclopramide (Reglan) 10 mg IV
         1. Excellent first-line agent for Migraine with Nausea
         2. Colman (2004) BMJ 329(7479): 1369-73
      3. Droperidol 0.625 to 2.5 mg IV or IM
      4. Consider Diphenhydramine (Benadryl) for Dyskinesia
   2. Avoid agents less effective in treating Headache
      1. Promethazine (Phenergan) 12.5 mg IV
      2. Hydroxyzine
4. Preparations: Serotonin Agonist
   1. Precautions
      1. Do not use if CAD, CVA, Uncontrolled Hypertension
      2. Do not use with MAO inhibitors, and Exercise caution with other serotonergic agents (e.g. SSRI)
   2. Dihydroergotamine mesylate (DHE)
      1. DHE 0.5 to 1 mg IV every 8 hours up to cummulative maximum of 3 mg
      2. Migranal 1 spray in each nostril and may repeat once after 15 minutes
   3. Triptans
      1. Sumatriptan (Imitrex) intranasl, oral or subcutaneous
      2. Zolmitriptan (Zomig) intranasal or oral
5. Preparations: Analgesic or Anti-inflammatory
   1. Toradol 60 mg IM
   2. Dexamethasone 4-10 mg IV (or 8-24 mg PO)
      1. Hydrocortisone or Methylprednisolone IV could be used as alternative (however Dexamethasone is preferred)
      2. May prevent Headache recurrence in following 48-72 hours
      3. Singh (2008) Acad Emerg Med 15(12): 1223-33
   3. Intranasal Lidocaine
      1. Position patient supine with head hyperextended with tilt to 30 degrees
      2. Lidocaine 4%, 0.5 ml of solution dripped into nostril on affected side over 30 seconds
   4. Opioids (avoid if possible)
      1. Still used in 47% of emergency visits
6. Preparations: Other agents that have been used historically
   1. Antipsychotics with Analgesic and Antiemetic properties
      1. Chlorpromazine (Thorazine) 12.5 mg IV q20 min prn x3
      2. Haloperidol (Haldol) 5 mg IV (pre-bolus 500 to 1000 cc of IV fluids)
   2. Anticonvulsant - Valproic Acid (Depacon)
      1. Depacon 300-1000 mg in 100 cc NS IV over 30 minutes
7. References
   1. Diamond (1997) Postgrad Med 101(1):169-79
   2. Kabbouche (2001) Pediatrics 107:e62
   3. Kelly (2000) West J Med 173:189-93
   4. Newman (1998) Neurol Clin 16(2):285-303
   5. Vinson (2003) Ann Emerg Med 41:90-7