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
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 |
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-1D receptors 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-1D receptors, 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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