Migraine in the Emergency Department

Class

Treatment

Side effect

Triptans

Sumatriptan 6 mg SC (max 12 mg/24 h)

Injection site reaction, paresthesias, hot/cold sensation, chest pressure/pain/tightness, dizziness, flushing, limb pain, vasoconstriction, and nausea

Ergotamine derivatives

Dihydroergotamine mesylate (DHE) 0.5 mg–1 mg IV. Can repeat q 1 h as needed (max 2 mg/24 h)

Paresthesias, dizziness, flushing, nausea/vomiting, diarrhea, dyspnea, rash, diaphoresis, elevated blood pressure, anxiety, and vasoconstriction

Courtesy of Mayo Foundation. Mayo Foundation retains ownership on original material

Table 31.2

Nonspecific migraine treatments in the emergency department

Class	Treatment	Side effect
Antiemetics (D2 antagonists)	Chlorpromazine 12.5–25 mg IV/IM	Drowsiness, dizziness, blurred vision, akathisia, dystonia, parkinsonism, fluid retention (metoclopramide), QT prolongation (droperidol has black box warning due to risk of QT prolongation), neuroleptic malignant syndrome, hypotension (especially chlorpromazine)
	Prochlorperazine 10 mg IV/IM
	Promethazine 25 mg IM
	Haloperidol 5 mg IV in 500 ml normal saline over 20 min
	Droperidol 2.5 mg IV ^a
	Metoclopramide 10 mg IV/IM
Antiepileptics	Valproate sodium 300–1,200 mg IV	Drowsiness, asthenia, nausea/vomiting, injection site reaction, dizziness, hepatotoxicity, hyperammonemia, pancreatitis
NSAIDs	Ketorolac 30 mg IV/IM	GI bleeding, GI ulceration, dyspepsia, abdominal pain, nausea, vomiting, injection site reaction, bleeding, rashes, nephrotoxicity, cardiovascular risk, anaphylaxis
	Acetylsalicylic acid 1 g IV
	(difficult to obtain in the United States)
	Diclofenac 75 mg IM
Corticosteroids	Dexamethasone 10–25 mg IV (prevents recurrence)	Nausea, vomiting, dyspepsia, dizziness, mood swing, insomnia, anxiety, hypertension, hyperglycemia, avascular necrosis of bone (rare)
Other	Magnesium sulfate 1–2 g IV	Hypotension, flushing, drowsiness

Courtesy of Mayo Foundation. Mayo Foundation retains ownership on original material

^a Continuous ECG monitoring should be initiated prior to administration and continued for 2–3 h after dosing

31.3.1 Triptans (5-HT _1B-1D Agonists)

Triptans are often the treatment of choice in acute migraine headache. The triptan class is an acute medication which specifically targets the 5-HT _1B-1Dreceptors present in the trigeminovascular system. Triptans should not be used within 24 h of a different triptan agent or dihydroergotamine. Triptans are contraindicated in the setting of coronary artery disease, cerebrovascular disease, peripheral vascular disease, uncontrolled hypertension, severe hepatic disease, hemiplegic migraine, migraine with brain-stem aura (dysarthria, ataxia, decreased consciousness, diplopia, etc.), and pregnancy. Triptans work well not only for pain but may also treat other associated symptoms such as photophobia, phonophobia, and nausea. If triptans are to be used in the emergency department, it is preferential to treat a patient with the subcutaneous formulation of sumatriptan as these patients typically have significant nausea and need rapid relief.

31.3.2 Dihydroergotamine (DHE)

This medication comprises another migraine-specific option. While DHE does have activity at the 5-HT _1B-1Dreceptors, it also exerts effects through interaction with serotonergic, adrenergic, and dopaminergic receptors. Similar to triptans, it should not be used in patients with vascular disease (peripheral, coronary, or stroke), uncontrolled hypertension, hemiplegic migraine, migraine with brain-stem aura, hepatic disease, pregnancy, or previous ergot or triptan use in the preceding 24 h. DHE can be used in a one-time fashion but can also be used repetitively for up to 2–5 days. Pretreatment with a D2 antagonist such as metoclopramide should be employed to prevent side effects of nausea that may be common with DHE when it is administered intravenously.

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