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treatment with opioids. It is often difficult or impossible to separate the drug
seeker from the true migraineur. So ultimately, clinical judgment must guide
the ED provider’s decision as to when and how to use opioids in the treatment
of this difficult condition. Although previously mentioned data suggest
opioids are often ineffective for MH, preliminary evidence from one small
RCT points to potential utility for an IV formulation of the mixed-mechanism
agent tramadol (administered 100 mg IV, in 100 mL saline, over 30 minutes).
Nearly three quarters of patients receiving tramadol had significant pain
relief, with about a third achieving complete analgesia after the single 100
mg IV dose. 59
Corticosteroid therapy has been suggested to be of potential utility in
patients with intractable MH. There is some evidence to suggest that dexamethasone
(8 mg IV) may be useful for resistant MH, but currently available
data do not support a recommendation for routine ED use. 60
Medication overuse headaches are encountered in the ED with increasing
frequency. While overuse of non-specific analgesics tends to cause tensiontype
headache pain, triptan overuse is usually manifest as recurrent MH. 61
For these patients, discontinuation of pharmacotherapy is the best approach.
Prophylactic medications that may have ED utility in the earliest stages of
migraine include the beta-blockers (e.g. metoprolol, propranolol) and the
calcium channel blockers (e.g. flunarizine). 33,38 A variety of other agents,
including antidepressants (e.g. amitriptyline) antiepileptics (e.g. topiramate),
vitamins (e.g. niacin) and even botulinum toxin, have been assessed
for MH but have no acute care indication. 62,63
n Summary and recommendations
First line: prochlorperazine (10 mg IV)
Reasonable:
n metoclopramide (10 mg IV)
n sumatriptan (6 mg SC) or other tripan (e.g. zolmitriptan 2.5 mg PO or 5 mg IN)
n combination therapy: oral sumatriptan (25 mg PO) plus naproxen 500 mg
Pregnancy: metoclopramide (10 mg IV)
Migraine and undifferentiated headache 247