Inpatient Treatment of Headache Make the Correct Diagnosis before Starting Treatment Is This a Primary Headache Disorder or Secondary Headache Disorder? Primary headache disorders are those like rebound headache, chronic daily headache, cluster headache, migraine. Secondary Headache disorders are those like the headaches caused by vasculitis, encephalitis/meningitis, tumors, increased intra-cranial pressure. Once you make the diagnosis of primary headache disorder, then ask if this disorder is characterized by focal neurologic deficits like seen in basilar migraine, such as hemiplegia, cranial neuropathies. Now, once I decide that a person has a primary headache disorder that is not characterized by focal deficits (an uncomplicated headache/migraine), then my primary inpatient treatment protocol will be to use Dihydroergotamine (DHE). If they have a primary headache disorder but there are focal features (which is a contraindication for using DHE), or the patient has other contraindications to DHE such as risk of or history of stroke or MI, then I tend to use IV Valproic Acid (Depacon). For secondary headache disorders, I can use either Depacon or other headache medications, but I'll often avoid DHE. Dihydroergotamine Protocols I have switched to using the continuous intravenous infusion rather than the repetitive infusions for several reasons. The most important was that with repetitive dosing there can develop difficulties when the medication is not delivered exactly on time with resultant frictions between the patient and nursing staff. With continuous dosing this is eliminated. Continuous Protocol Versus Repetitive Dosing Taken from "Continuous Intravenous Dihydroergotamine in the Treatment of Intractable Headache" from Headache, March 1997 by Ford. Its important to know the rates at which patients became headache free, so that correct expectations can be set. Continuous Infusion of DHE -- Percentage of Patients Headache Free 1 day: 12.5% 2 days: 36.5 % 3 days: 64.5 % 4 days: 80 % 5 days: 87.5 % 6 days: 90.5 % 7 days: 92.5 % Repetitive IV DHE - Percentage of Patients Headache Free 1 day: 16% 2 days: 33 % 3 days: 66.5 % 4 days: 74.5 % 5 days: 76 % 6 days: 85 % 7 days: 86.5 % Here Are the Two DHE Protocols from the Ford Clinic Article Continuous IV DHE Protocol 1. Start IV for administration of dihydroergotamine mesylate (DHE 45) 3mg in 1000 mL of normal saline. 2. Give Metoclopramide (Reglan) 10mg IV in 50mL normal saline over 30 minutes at the start of the DHE infusion. 3. Begin DHE 3 mg in 1000 mL normal saline at 42 mL/hr 4. Continue Reglan 10mg IV q 8 hours for 5 additional doses prn nausea 5. Give diphenoxylate with atropine (Lomotil), one to two tablets tid prn diarrhea. 6. If excessive anxiety or jitterness (akathsia) occurs, have IV benztropine (Cogentin) 1mg available for IV use for akathesia or dystonic reaction. IV Diphenhydramine (Benadryl) 25 - 50 mg is also useful. 6. If significant nausea occurs at any time, reduce the rate of DHE to 21 to 30 mL/hr. Raskin's Repetitive IV DHE Protocol - Modified 1. Place a heparin lock IV for dihydroergotamine mesylate (DHE 45) and metoclopramide (Regland) administration. 2. Give 10mg of Reglan in 50 ML normal saline over 30 minutes IV. Then, give a test dose of 0.5 mg DHE IV over 2 minutes. Always give Reglan 10mg in normal saline over 30 minutes prior to giving DHE and stop Reglan after the first six doses. 3. If the patient becomes nauseated, and if headache is relieved in 1 hour, give no further DHE for 8 hours. The next 8-hour dose of DHE will be 0.3 mg 10 minutes after IV Reglan. If the patient becomes nauseated from 0.3 mg of DHE, the dosage of DHE will be 0.25 mg q8 hours. 4. If headache is relieved with the initial dose of 0.5mg of DHE and the patient is not nauseated, the dosage of DHE will remain 0.5 mg q8 hours. 5. If the patient is not nauseated from the 0.5 mg test dose, and the headache continues after the test dose of 0.5 mg, give an additional 0.5 mg of DHE 1 hour later without Reglan. If the patient becomes nauseated following the second dose of 0.5 mg, then the next 8-hour dose will be 0.75 mg. If, however, the patient is not nauseated after the second test dose of 0.5 mg, the dosage will be 1mg DHE q 8 hour until ordered otherwise. 6. Give diphenoxylate with atropine (Lomotil), one to two tablets tid prn diarrhea. 7. If excessive anxiety or jitterness (akathsia) occurs, have IV benztropine (Cogentin) 1mg available for IV use for akathesia or dystonic reaction. IV Diphenhydramine (Benadryl) 25 - 50 mg is also useful. Use of Rescue Medication I try to limit the use of rescue medications, especially in those patients I believe have rebound headache. I rarely use narcotics. If necessary, I will try Dexamethasone 10 mg q 8 hours IV for 24 hours perhaps 48 hours, Chlorpromazine (Thorazine), 10 mg in 50 mL normal saline over 20 minutes (limiting it to once or twice), or Ketorolac (Toradol) 30-60 mg IV (though limiting this to once or twice) Preventative Medication Continue or start the patient on a preventative medication at the same time as you are using the DHE. I often start appropriate patients on Depakote 500mg ER once a day. Topamax or Neurontin could also be used. Other Pain Medications I'm not sure this protocol will work with patients who have rebound headache and who continue taking copious amounts of pain medications other than that allowed on the protocols. If this becomes a problem, I usually stop the admission. I've had little to no success in treating refractory primary headache syndromes as an inpatient with medications other than DHE, Depacon or occasionally medications like Reglan, Compazine or Thorazine. I've not been successful using narcotics in the inpatient treatment of primary headache disorders. I have used repetitive dosing of Thorazine 12.5 mg every 8 hours for 3 days with some success in a patient who had contraindications to both DHE and Depacon. Depacon (Valproic Acid) Protocol This is simple 1. Depacon 500 mg IV infused at 20-30 mg/min given q 8 hours 2. Either Reglan 10 mg IV, Compazine 10mg IV, or Thorazine 12.5 mg IV q 8 hours prn nausea (or sometimes used as rescue medications). 3. If excessive anxiety or jitterness (akathsia) occurs secondary to the antiemetics, have IV benztropine (Cogentin) 1mg available for IV use for akathesia or dystonic reaction. IV Diphenhydramine (Benadryl) 25 - 50 mg is also useful. 3. Continue this for 3 days total. 4. Patient leaves the hospital on either 500 mg or 1000 mg of Depakote ER once a day. DRUG SIDE EFFECTS , ADVERSE REACTIONS AND USE OF THIS INFORMATION: Avoid Depakote in patients with liver problems, and be aware that Depakote interacts with many medications. Make sure you look up both Depakote (Depacon) and DHE and know their indications, adverse reactions, side effects, and contraindications before you use these. As well, realize that I may have made an error somewhere above in the dosing, use your professional judgement and double check any doses and frequencies listed above before using these protocols. I have provided this on the web for my personal use and to those providers whom work with me at my home institution. This is not intended to be used by other persons.

Inpatient Treatment of Headache

Make the Correct Diagnosis before Starting Treatment

Is This a Primary Headache Disorder or Secondary Headache Disorder?

Primary headache disorders are those like rebound headache, chronic daily headache, cluster headache, migraine.

Secondary Headache disorders are those like the headaches caused by vasculitis, encephalitis/meningitis, tumors, increased intra-cranial pressure.

Once you make the diagnosis of primary headache disorder, then ask if this disorder is characterized by focal neurologic deficits like seen in basilar migraine, such as hemiplegia, cranial neuropathies.

Now, once I decide that a person has a primary headache disorder that is not characterized by focal deficits (an uncomplicated headache/migraine), then my primary inpatient treatment protocol will be to use Dihydroergotamine (DHE).

If they have a primary headache disorder but there are focal features (which is a contraindication for using DHE), or the patient has other contraindications to DHE such as risk of or history of stroke or MI, then I tend to use IV Valproic Acid (Depacon).

For secondary headache disorders, I can use either Depacon or other headache medications, but I'll often avoid DHE.

Dihydroergotamine Protocols

I have switched to using the continuous intravenous infusion rather than the repetitive infusions for several reasons. The most important was that with repetitive dosing there can develop difficulties when the medication is not delivered exactly on time with resultant frictions between the patient and nursing staff. With continuous dosing this is eliminated.

Continuous Protocol Versus Repetitive Dosing

Taken from "Continuous Intravenous Dihydroergotamine in the Treatment of Intractable Headache" from Headache, March 1997 by Ford.

Its important to know the rates at which patients became headache free, so that correct expectations can be set.

Continuous Infusion of DHE -- Percentage of Patients Headache Free

1 day: 12.5%

2 days: 36.5 %

3 days: 64.5 %

4 days: 80 %

5 days: 87.5 %

6 days: 90.5 %

7 days: 92.5 %

Repetitive IV DHE - Percentage of Patients Headache Free

1 day: 16%

2 days: 33 %

3 days: 66.5 %

4 days: 74.5 %

5 days: 76 %

6 days: 85 %

7 days: 86.5 %

Here Are the Two DHE Protocols from the Ford Clinic Article

Continuous IV DHE Protocol

1. Start IV for administration of dihydroergotamine mesylate (DHE 45) 3mg in 1000 mL of normal saline.

2. Give Metoclopramide (Reglan) 10mg IV in 50mL normal saline over 30 minutes at the start of the DHE infusion.

3. Begin DHE 3 mg in 1000 mL normal saline at 42 mL/hr

4. Continue Reglan 10mg IV q 8 hours for 5 additional doses prn nausea

5. Give diphenoxylate with atropine (Lomotil), one to two tablets tid prn diarrhea.

6. If excessive anxiety or jitterness (akathsia) occurs, have IV benztropine (Cogentin) 1mg available for IV use for akathesia or dystonic reaction. IV Diphenhydramine (Benadryl) 25 - 50 mg is also useful.

6. If significant nausea occurs at any time, reduce the rate of DHE to 21 to 30 mL/hr.

Raskin's Repetitive IV DHE Protocol - Modified

1. Place a heparin lock IV for dihydroergotamine mesylate (DHE 45) and metoclopramide (Regland) administration.

2. Give 10mg of Reglan in 50 ML normal saline over 30 minutes IV. Then, give a test dose of 0.5 mg DHE IV over 2 minutes. Always give Reglan 10mg in normal saline over 30 minutes prior to giving DHE and stop Reglan after the first six doses.

3. If the patient becomes nauseated, and if headache is relieved in 1 hour, give no further DHE for 8 hours. The next 8-hour dose of DHE will be 0.3 mg 10 minutes after IV Reglan. If the patient becomes nauseated from 0.3 mg of DHE, the dosage of DHE will be 0.25 mg q8 hours.

4. If headache is relieved with the initial dose of 0.5mg of DHE and the patient is not nauseated, the dosage of DHE will remain 0.5 mg q8 hours.

5. If the patient is not nauseated from the 0.5 mg test dose, and the headache continues after the test dose of 0.5 mg, give an additional 0.5 mg of DHE 1 hour later without Reglan. If the patient becomes nauseated following the second dose of 0.5 mg, then the next 8-hour dose will be 0.75 mg. If, however, the patient is not nauseated after the second test dose of 0.5 mg, the dosage will be 1mg DHE q 8 hour until ordered otherwise.

6. Give diphenoxylate with atropine (Lomotil), one to two tablets tid prn diarrhea.

7. If excessive anxiety or jitterness (akathsia) occurs, have IV benztropine (Cogentin) 1mg available for IV use for akathesia or dystonic reaction. IV Diphenhydramine (Benadryl) 25 - 50 mg is also useful.

Use of Rescue Medication

I try to limit the use of rescue medications, especially in those patients I believe have rebound headache. I rarely use narcotics. If necessary, I will try Dexamethasone 10 mg q 8 hours IV for 24 hours perhaps 48 hours, Chlorpromazine (Thorazine), 10 mg in 50 mL normal saline over 20 minutes (limiting it to once or twice), or Ketorolac (Toradol) 30-60 mg IV (though limiting this to once or twice)

Preventative Medication

Continue or start the patient on a preventative medication at the same time as you are using the DHE. I often start appropriate patients on Depakote 500mg ER once a day. Topamax or Neurontin could also be used.

Other Pain Medications

I'm not sure this protocol will work with patients who have rebound headache and who continue taking copious amounts of pain medications other than that allowed on the protocols. If this becomes a problem, I usually stop the admission. I've had little to no success in treating refractory primary headache syndromes as an inpatient with medications other than DHE, Depacon or occasionally medications like Reglan, Compazine or Thorazine. I've not been successful using narcotics in the inpatient treatment of primary headache disorders. I have used repetitive dosing of Thorazine 12.5 mg every 8 hours for 3 days with some success in a patient who had contraindications to both DHE and Depacon.

Depacon (Valproic Acid) Protocol

This is simple

1. Depacon 500 mg IV infused at 20-30 mg/min given q 8 hours

2. Either Reglan 10 mg IV, Compazine 10mg IV, or Thorazine 12.5 mg IV q 8 hours prn nausea (or sometimes used as rescue medications).

3. If excessive anxiety or jitterness (akathsia) occurs secondary to the antiemetics, have IV benztropine (Cogentin) 1mg available for IV use for akathesia or dystonic reaction. IV Diphenhydramine (Benadryl) 25 - 50 mg is also useful.

3. Continue this for 3 days total.

4. Patient leaves the hospital on either 500 mg or 1000 mg of Depakote ER once a day.

DRUG SIDE EFFECTS , ADVERSE REACTIONS AND USE OF THIS INFORMATION: Avoid Depakote in patients with liver problems, and be aware that Depakote interacts with many medications. Make sure you look up both Depakote (Depacon) and DHE and know their indications, adverse reactions, side effects, and contraindications before you use these. As well, realize that I may have made an error somewhere above in the dosing, use your professional judgement and double check any doses and frequencies listed above before using these protocols. I have provided this on the web for my personal use and to those providers whom work with me at my home institution. This is not intended to be used by other persons.