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Low dosages should be used initially, as superior efficacy for some dopamine receptor antagonists, including metoclopramide, droperidol, and prochlorperazine, has been demonstrated at lower doses compared to higher doses.
Pretreatment with IV benztropine or diphenhydramine is recommended to minimize or avoid extrapyramidal side effects, especially with dopamine receptor antagonists that have a high incidence of posttreatment akathisia and dystonia.
Akathisia, a common adverse event secondary to dopamine receptor antagonists, can eliminate any positive headache response from these medications, because it can be as disabling to the patient as the pain itself.
A recent systematic review looked at 34 studies, including eight trials, assessing the efficacy of ketorolac for the acute treatment of migraine.
The Canadian Headache Society strongly recommends IM or IV ketorolac for migraine treatment in the ED based on a systematic review of the literature, clinical experience, and a favorable side effect profile.
It is very common to see the addition of IV corticosteroids to a migraine treatment regimen in the ED.
In a recent meta-analysis, 25 studies involving 3989 patients indicate the potential benefit of using IV dexamethasone to prevent headache recurrence up to 72 hours after discharge from the ED.
IV antiepileptic drugs.
IV sodium valproate typical dosing 500 mg to 1000 mg has some support for its use in open-label studies and some recent support in comparator trials, but no placebo-controlled studies have evaluated its efficacy in patients with status migrainosus or intractable migraine.
It is known that oral combination therapy with valproic acid and topiramate can cause this metabolic response, but it is somewhat alarming that it can occur after a single IV dose of medication.
Continuum Minneap Minn;21 —1017 Opioids.
A crisis exists in the United States and other countries around the world with the inordinate amount of opioids being used for noncancer pain syndromes.
One of the largest culprits is the use of opioids for migraine in the ED. Looking at the data, opioids are typically less effective, at most, equally effective as multiple nonopioid acute migraine treatments, including ketorolac,20 DHE,21,22 corticosteroids,23 and multiple dopamine receptor antagonist compounds.
Opioids drain medical resources, as they have been shown to lead to an increase in headache relapse and need for a return to the ED for further treatment.
This does not relate at all to the effectiveness of these medications.
Prior to use, however, the patient should be cleared from a cardiac standpoint with a normal ECG and should have no history of thunderclap headache, hemiplegic migraine, or prolonged aura.
The consulting neurologist is likely not completely familiar with the cardiac and stroke history of the patient as well as the migraine aura history eg, if the patient ever had prolonged auras or a history of hemiplegic auras.
If these medications are felt to be necessary and the patient has not had a recent ECG, an ECG should be obtained to look for ischemic changes. Contraindications to the use of triptans and DHE include uncontrolled hypertension, past stroke or myocardial infarction, peripheral vascular disease, and certain types of aura, including hemiplegic aura and prolonged more than 1 hour aura.
Nerve blockade. If IV therapy in the ED has failed and the patient continues to have unabated head pain, then a greater occipital nerve block can be helpful.