Emergency room treatment of migraines

Narcotic (opioid) drugs are still widely prescribed by doctors in offices and emergency rooms. They are not only potentially addictive, but also are not effective for the treatment of migraine headaches. The guidelines of the American Academy of Neurology call for avoidance of opioids for migraine and headache.

Doctors at the Cleveland Clinic developed a detailed, step-by-step algorithm that has dramatically reduced the use of narcotics for migraine management in the emergency room and prescribing of them upon discharge.

In the three months before the algorithm was implemented 66% of migraine patients had received narcotics in the ER and 44% had discharge prescriptions for these medications. After algorithm implementation, the rates were 19% and 5%, respectively.

The results of this study were presented at the 2015 annual meeting of the American Headache Society.

The first step of the algorithm involves using a three-question screener for diagnosing migraine. The questions elicited the presence of nausea, sensitivity to light and inability to function normally. If two of these three symptoms were present, migraine diagnosis was made, provided no other serious condition was causing the headache. Doctors then evaluated for potential drug-seeking behavior and repeated ER visits without appropriate follow-up with the patient’s primary care provider.

The first step was intravenous or intramuscular injection of a nonsteroidal anti-inflammatory pain medicine ketorolac (Toradol) plus a nausea drug, metoclopramide (Reglan) plus an anti-histamine, diphenhydramine (Benadryl). If the patient did not experience at least 50% pain relief, step 2 was a steroid medication, dexamethasone (Decadron) plus valproate sodium (Depacon) plus magnesium sulfate. Step 3 used in patients who didn’t experience at least 50% pain relief was a subcutaneous injection of sumatriptan, which was repeated in one hour if the headache did not resolve. If the patient failed sumatriptan in the past, dihydroergotamine (DHE-45) was given with a nausea drug prochlorperazine (Compazine), metoclopramide (Reglan) or ondansetron (Zofran).

If patients do not respond to the third step, they are considered for hospital admission and admission did increase from 8% to 25%.

It is a very good algorithm and if you suffer from severe migraines that at times land you in an ER, I would keep this list of injectable drugs, so that you can ask for them. However, I would ask for intravenous magnesium to be given first since it has a 50% chance of helping without side effects, which can occur with every other drug. I would also use sumatriptan after magnesium since it is very effective and is the only migraine-specific drug available in an injection. Studies suggest that diphenhydramine (Benadryl) and valproex sodium (Depacon) are not very effective, so I would avoid those if you have a choice.

5 comments
  1. Julie says: 11/06/20151:47 am

    This is a wonderful resource you’ve provided for both medical practitioners and people who suffer from headaches and migraines. Thank you so much for doing this blog! I’m really grateful to come across it!

  2. Dr. Mauskop says: 11/05/201510:39 am

    Yes, steroids can help – see this post for more details.

  3. Kelsey says: 11/04/20153:33 pm

    I’ve been experiencing migraines every other day for the past 2 1/2 weeks and almost went to the ER yesterday but made it through. My neurologist wants me to take a short course of corticosteroids to break the migraine cycle. Is this something you’ve seen work? I just went through a very stressful few months and didn’t get any migraines during, but I always get let down migraines. Thank you!

  4. Dr. Mauskop says: 10/04/20159:49 pm

    Yes, if none of these treatments succeed, it is reasonable to consider opioids. Unfortunately, they often fail, and even make nausea and other symptoms worse. We have a very small number of migraine patients who respond only to opioids and not any migraine-specific drugs. However, these patients are exceptions, which confirm the rule. Besides opioids, an acute migraine might respond to nerve blocks of the occipital and branches of the trigeminal nerves with lidocaine. This is a particularly good option for pregnant women with a persistent migraine, which has not responded to IV magnesium.

  5. shannon says: 10/04/20153:52 am

    That sounds like a good algorithm for the ER. But the ER is often unlikely to repeat a drug combination that is unsuccessful if admission is required. Do you suggest repeating these meds if they failed in the ER upon admission, or is then the time when it is time to consider opioids on a case by case basis?

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