Mx of acute migraine

see migraine, neurology, pain, analgesia and analgesics, headache

see also:

• NICS - Mx of acute migraine 006 (pdf)

• look for alarm symptoms & signs of headaches that may warrant a CT scan or alternate diagnosis
• in general oral medications in acute attacks are poorly absorbed even with anti-emetic or in non-nauseated pts!!

• simple pain, analgesia and analgesics:
  • paracetamol (acetaminophen) +/- codeine
  • non-steroidal anti-inflammatory drugs (NSAIDs) if not pregnant and no other C/I:
    • aspalgin x ii or iii
    • indomethacin suppository 100mg
• PLUS an anti-emetic to improve GIT absorption and prevent vomiting eg. metoclopramide (Maxolon) 10mg

• if not pregnant, consider a triptan such as oral sumatriptan 100mg especially for the patient at home
• many migraineurs gain relief from mersyndol for outpatient use when they can sleep it off.

• consider admission into ED short stay observation unit
• NB. opiates and opioids should be avoided as dependency and nausea/vomiting are problematic in migraine sufferers

• IV chlorpromazine (Largactil)
  • has been shown to be more effective in EDs than SC sumatriptan
  • administration options for adults designed to minimise hypotension from iv chlorpromazine:
    • chlorpromazine 25mg in 500 or 1000 ml saline infused stat. Q 8 hr prn, or,
    • chlorpromazine 12.5 mg as “push” dose after 300 ml saline fluid bolus. IV fluids must continue. Can be repeated every 30 minutes to maximum of 37.5 mg (depending on migraine severity)
• titrated iv doses of propofol
  • must be given in a resus. room by senior ED doctors
  • appears to be very effective in terminating migraine
  • adults have been given 20mg doses every 10min until pain free
  • median doses are around 75mg (20-140mg) and median time to pain free 48min (10-180min); ~5% have recurrences within 24hrs requiring further doses of propofol ¹⁾
• iv paracetamol or parenteral non-steroidal anti-inflammatory drugs (NSAIDs):
  • considerably reduces pain scores at 15min and 30min post-infusion
  • 24-33% will need rescue Rx such as with either of the above medications
  • may be useful for those who do not tolerate phenothiazines²⁾
• iv sodium valproate (Epilim)
  • requires further study but 900-1200mg iv valproate appeared to substantially reduce migraine headache pain within 60 minutes in ~75% of patients ³⁾

• Treatment of Children With Migraine in the Emergency Department: A Qualitative Systematic Review. Pediatric Emergency Care. Volume 24(5), May 2008. Hosted on NICS blog
• in 2018, US FDSA approves Aimovig, a parenteral calcitonin gene–related peptide (CGRP) blocker for prophylaxis of migraine
• in Dec 2019, US FDA approves Ubrogepant (Ubrelvy), an oral calcitonin gene–related peptide (CGRP) blocker for Rx of acute migraine