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246 Migraine and undifferentiated headache
The utility of the triptans in cluster headache is outlined in a separate
chapter of this text.
Vasospasm-mediated serious adverse effects such as stroke and myocar-
dial infarction have been reported with triptan use. 43,44 The risk of these
serious adverse effects can be reduced to acceptably low levels by limiting use
of triptans to patients lacking history of, or significant risk factors for, vascular
disease. 45
Combination therapy with PO sumatriptan (85 mg) and the NSAID
naproxen (500 mg) results in significantly better pain relief than monotherapy
with either agent. 31
Controlled trials demonstrate efficacy of multiple NSAIDs for MH pain.
Among those drugs performing better than placebo are aspirin, ibuprofen,
tolfenamic acid, diclofenac, and naproxen. 46–53 Ketorolac offers the advantage
of parenteral administration. Although no placebo-controlled data are
available, this injectable NSAID appears to be effective either IV or IM. 53,54
Patients presenting to ED with MH usually require a more potent analgesic
than acetaminophen (paracetanol). There are RCT data demonstrating
utility of acetaminophen. 55 The primary use will be for occasional cases in
which patients have not tried pre-ED analgesia. Investigators report some
MH pain relief from combination therapy with acetaminophen and a mild
opioid, although opioids such as codeine may exacerbate MH-associated
nausea. 56
Despite their non-specific mechanism of action, opioids are frequently
used for MH. Evidence supporting use of this class is limited, and rigorous
placebo-controlled trials are lacking. Data addressing use of meperidine
consistently find this opioid to be no better than (and often inferior to)
alternative non-opioid drugs. 13,57 Intranasal administration of butorphanol
achieves better MH relief than placebo, but the agonist–antagonist can cause
problematic side effects such as nausea and dysphoria. 58
While there is no good evidence to prove benefit of opioids for MH (or
other headache syndromes), it is hard to conceive of providing ED care
without having access to this class, at least for rescue therapy. Many chronic
headache sufferers report allergies or non-effectiveness of non-opioid regimens.
Additionally, many primary care physicians send patients to the ED for