Do not be a fool! This web-page is for use by Dr. Beck and may have significant errors in it. Do your own double checking if you stumble on this web-page. ER Treatment of Migraine Rule # 1: Make sure its migraine You don't want to treat a subarachnoid hemorrhage with Triptans Rule # 2: Avoid medication with narcotics and barbiturates, especially with the patients with frequent headaches. Rule #3: Remember side effects and interactions. Tell your patients what to expect before you hit them with a powerful medication. Drugs I Have Found Useful in the ER (listed in no certain order) Magnesium Sulfate IV 1-2 grams over 10-30 minutes Common side effects of flushing and hypotension. Thorazine 12.5 - 25 mg IV Common side effects of agitation and sedation Consider IV Benadryl 12.5mg-50mg for side effects of agitation/akathesia, though it will cause significant sedation. Compazine 12.5 to 25 mg IV/po/pr Same side effects as Thorazine Reglan 10-20 mg IV/po/pr Ketrolac (Toradol) 30-60 mg IV DHE (Dihydroergotamine) Can be given IM/SC as well if no IV access test dose of 0.5 mg IV given slowly over 15 minutes, if tolerated well, then may give another 0.5 mg dose for a total of 1 mg. Side effects similar to Triptans, though may be somewhat worse. You can give it slowly, say over an hour or more, and it may decrease the side effects. Triptans Sumatriptan 4-6 mg SC (by the time I'm called to the ER I usually consider using SC version rather than PO, but I'd consider PO) tell patient about tachycardia, chest pressure and the other expected side effects Anti-Seizure Medications Depakote IV bolus of 500 to 1000 mg (most studies gave 500 mg) given at 50 mg/minute may be helpful. I have used it in addition to starting the patient the next day on Depakote Extended Release at 500 mg per day. This may be useful in a patient with frequent headaches who will need preventative medication started. Steroids Dexamethasone 4-6 mg IV, or Prednisone 100 mg I usually use this in combination with other medications. One study suggested that steroids added on to a migraine regimen in the ER had the effect of reducing headache recurrence at 24 hours. Other Treatments I sometimes combine medications, such as giving Thorazine, Magnesium and Toradol in combination Thorazine or Compazine plus DHE is a good combination also Naproxen 500 mg every 12 hours for the next three to five days after the ER visit may reduce the recurrence of the headache when the patient goes home. An Easy to Read Article from American Academy of Family Physicians on Management of Acute Migraine

Do not be a fool! This web-page is for use by Dr. Beck and may have significant errors in it. Do your own double checking if you stumble on this web-page.

ER Treatment of Migraine

Rule # 1:

Make sure its migraine

You don't want to treat a subarachnoid hemorrhage with Triptans

Rule # 2:

Avoid medication with narcotics and barbiturates, especially with the patients with frequent headaches.

Rule #3:

Remember side effects and interactions. Tell your patients what to expect before you hit them with a powerful medication.

Drugs I Have Found Useful in the ER

(listed in no certain order)

Magnesium Sulfate IV

1-2 grams over 10-30 minutes

Common side effects of flushing and hypotension.

Thorazine

12.5 - 25 mg IV

Common side effects of agitation and sedation

Consider IV Benadryl 12.5mg-50mg for side effects of agitation/akathesia, though it will cause significant sedation.

Compazine

12.5 to 25 mg IV/po/pr

Same side effects as Thorazine

Reglan

10-20 mg IV/po/pr

Ketrolac (Toradol)

30-60 mg IV

DHE (Dihydroergotamine)

Can be given IM/SC as well if no IV access

test dose of 0.5 mg IV given slowly over 15 minutes, if tolerated well, then may give another 0.5 mg dose for a total of 1 mg.

Side effects similar to Triptans, though may be somewhat worse. You can give it slowly, say over an hour or more, and it may decrease the side effects.

Triptans

Sumatriptan 4-6 mg SC (by the time I'm called to the ER I usually consider using SC version rather than PO, but I'd consider PO)

tell patient about tachycardia, chest pressure and the other expected side effects

Anti-Seizure Medications

Depakote IV bolus of 500 to 1000 mg (most studies gave 500 mg) given at 50 mg/minute may be helpful. I have used it in addition to starting the patient the next day on Depakote Extended Release at 500 mg per day. This may be useful in a patient with frequent headaches who will need preventative medication started.

Steroids

Dexamethasone 4-6 mg IV, or Prednisone 100 mg

I usually use this in combination with other medications. One study suggested that steroids added on to a migraine regimen in the ER had the effect of reducing headache recurrence at 24 hours.

Other Treatments

I sometimes combine medications,

such as giving Thorazine, Magnesium and Toradol in combination

Thorazine or Compazine plus DHE is a good combination also

Naproxen 500 mg every 12 hours for the next three to five days after the ER visit may reduce the recurrence of the headache when the patient goes home.

An Easy to Read Article from American Academy of Family Physicians on Management of Acute Migraine