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Treatment of Acute Migraine Headache in the Emergency Department

Thursday, April 19, 2018  
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Madelyn Stabinski, Duquesne University PharmD Candidate of 2020

David E. Zimmerman, PharmD, BCPS, BCCCP, Assistant Professor at Duquesne University

 

Introduction

Working in the emergency department can be an uphill battle when the opioid crisis is currently on the rise and up to 77% of patients present with pain as a chief complaint.1 Acute migraine headaches account for 2-3% of emergency department visits and consequently costs upwards of $700 million dollars annually to treat. Approximately 13% of all adults in the United States are affected by acute migraine headaches, therefore practitioners need to be aware of the available treatments so that migraines can be quickly and effectively treated. Migraine headaches can be described as throbbing on one side of the head which may cause a person to feel nauseous, dizzy, extremely sensitive to stimuli such as light and sound, and is overall debilitating to daily activities.2 Diagnosis of an acute migraine headache can be achieved by using the POUND mnemonic; pulsatile, one-day duration, unilateral, nausea and vomiting, and disabling.3 How should health care professionals go about treating migraine headaches? And how does one decide when an opioid may be the necessary choice? These are questions that must be taken into consideration when selecting appropriate therapy for these patients.

 

Pharmacologic Treatment

There are several pharmacologic options to treat an acute migraine headache in the emergency department and sometimes a “broad spectrum approach” of agents that target various receptors may be used. It is important to ask the patient if they have been treated previously, and if so, what agents have worked for them. One popular treatment option is the NSAID ketorolac (Toradolâ). Recommended doses for treating acute migraine headaches are 15-30 mg intravenously, or 60 mg intramuscularly with a maximum daily dose of 120 mg. Contraindications for ketorolac include patients with peptic ulcers, severe asthma, and those who are pregnant.4 Ketorolac should also be avoided in patients with acute kidney injury. The American Headache Association states that Ketorolac works particularly well in patients whose migraine has spread throughout the entire head and into the shoulders, and in patients whose headache progressed overnight into a migraine upon awakening.5 Typically, acetaminophen (Tylenolâ) and triptans may be avoided as the patient may have already tried one of these options before coming to the emergency room. If acetaminophen is used, make sure to find out how much the patient has already taken to avoid going over the daily recommended amount. Along with ketorolac, intravenous fluids and antiemetics are administered to rehydrate the patient and decrease nausea.3 Fluids play an integral role in the treatment of migraine headaches because vomiting can cause extreme fluid loss, and proper hydration protects the kidneys from the damaging effects of ketorolac.4 Metoclopramide (Reglanâ) and prochlorperazine (Compazineâ), both antiemetics, are commonly used  agents to aid in the reduction of nausea and migraine cessation.3 Metoclopramide has been shown to be most efficacious when given as a single intravenous dose, ranging from 10 mg to 20 mg.6 The most frequently used dose of prochlorperazine is 10 mg given via IV or IM injection. Diphenhydramine (Benadrylâ) is routinely administered concomitantly with metoclopramide or prochlorperazine to decrease the risk of a patient developing anti-dopaminergic adverse effects.4 If the above medications did not resolve the patient’s migraine then several other therapies could be utilized. Typical second line therapies include IV valproic acid (Depaconâ) and IV magnesium. A common preventative measure is the administration of parenteral dexamethasone (Decadronâ) upon discharge which has been shown to decrease the migraine recurrence rate at 24 hours.4

 

 

Table 11-5, 7-12

Drug

Dosing

Monitoring

Contraindications/ Limitations

Adverse Events

Ketorolac (Toradolâ)

15-30 mg IV

60 mg IM

-Do not exceed a maximum daily dose of 120 mg

-Monitor for any changes in pain

-Contraindicated in patients with peptic ulcers, severe asthma, pregnant, and chronic kidney disease

-Used with caution in patients with a high cardiovascular risk profile or acute kidney injury

GI upset

Valproic Acid (Depaconâ)

500-1000 mg infused over 10-15minutes

-Monitor for drug-drug interactions

-Contraindicated in pregnancy, liver disease, and urea cycle defects

 

Magnesium

1-2 gms IV

-Transient hypotension

-Use caution in patients with renal impairment

-Flushing

-Loose stools

Metoclopramide (Reglanâ)

10-20mg IV

-Akathisia

-Postural hypotension

-------

-Drowsiness

Prochlorperazine (Compazine)

10 mg IV or IM

-Akathisia

-------

-Sedation

-Postural hypotension

Diphenhydramine (Benadrylâ)

25-50 mg IV

-Sedation

-Anticholinergic adverse effects

-Use caution in elderly

-Use caution in patients with cardiovascular disease

-Drowsiness

Dexamethasone (Decadronâ)

10 mg slow IV push

-Drug-drug interactions

-------

-Dizziness

-GI upset

-Mild Sedation

 

 

Opioid Treatment

Opioid therapy should not be considered as a first line option in the treatment of migraine headaches, but there are circumstances where an opioid medication may be employed. Pregnant women may be candidates to receive opioid therapy due to the fact that ergotamine tartrate and serotonin 5-HT1Band 5-HT1Dreceptor agonists, also known as the “triptans”, are contraindicated in pregnancy. The use of opioids in pregnant woman should not be considered unless treatment failure with the use of fluids and antiemetics. If an opioid therapy is indicated, a onetime dose of an immediate release formulation is used. Typically, 5 mg of immediate release oxycodone (Roxicodoneâ) is used if necessary. The use of an opioid should only be used in the emergency department, not for chronic migraine therapy. As a general practice, opioids should be avoided because of the increased risk for relapse, opioid addiction, and medication overuse headaches.4 Therapies targeted specifically at migraines are not always implemented as first line, and it is our duty as health care professionals to educate others about the consequences of overusing opioids.1

 

Nonpharmacological Treatment

Patient education plays a key role in the prevention of acute migraine headaches. There are several ways in which migraine headaches can be avoided without the use of medication. In patients who frequently experience migraines, it is noted that the brain does not withstand a great deal of change or stress. As health professionals, we must educate the patient on trigger avoidance; triggers may vary from patient to patient. If a patient is unaware of what his or her “triggers” are, a diary may be beneficial in finding what provokes the onset of a migraine. It is recommended that all patients have adequate sleep, meals, hydration, and exercise. Avoiding stressful situations is also crucial, but may not always be possible.13 Therapies such as transcutaneous electrical nerve stimulation, acupuncture, and laser therapy have shown to decrease the days in which migraine headaches occur.14 Educating patients on ways to avoid migraines, as mentioned above, can reduce the amount of emergency room visits.

 

Conclusion

Overall, migraine headaches are a burden to daily activities which consequently leads to a diminished quality of life for these patients. As health care providers, we need to be aware of the various treatment options and utilize these therapies before turning to opioids. It is crucial that treatment options such as ketorolac plus metoclopramide are utilized, along with patient education upon discharge. If all health care professionals are made aware of the various migraine therapies, it could significantly decrease the amount of time patients spend in the emergency department with migraine headaches and reduce the number of relapses.

 

 

References:

1.     Knox TH. A Review of Current and Emerging Approaches to Pain Management in the Emergency Department. Pain Ther. 2017 Dec; 6(2):193-202. DOI 10.1007/s40122-017-0090-5.

2.     Najjar M, Hall T, Estupinan B. Metoclopramide for Acute Migraine Treatment in the Emergency Department: An Effective Alternative to Opioids. Cureus. 2017 Apr; 9(4): e1181. DOI 10.7759/cureus.1181.

3.     Gupta S, Oosthuizen R, Pulfrey S. Treatment of acute migraine in the emergency department. Can Fam Physician. 2014 Jan; 60(1):47-49.

4.     Gelfand AA, Goadsby PJ. A Neurologist’s Guide to Acute Migraine Therapy in the Emergency Room. Neurohospitalist. 2012 Apr; 2(2):51-59.

5.     Tepper D, Non-Steroidal Anti-Inflammatories for the Acute Treatment of Migraine. J Headache Pain. 2012 Dec; 53(1):225-226.

6.     Evers S, Áfra J, Frese A, Goadsby PJ, Linde M, May A, et al. EFNS guideline on the drug treatment of migraine- revised report of an EFNS task force. Eur J Neurol. 2009 Sept;6(9):968-981.

7.     Friedman BW, Lipton RB. Headache Emergencies: Diagnosis and Management. Neurol Clin. 2012 Feb; 30(1):43-59.

8.     Friedman BW, Mulvey L, Esses D, Solorzano C, Paternoster J, Lipton RB, et al. Metoclopramide for Acute Migraine: A Dose-Finding Randomized Clinical Trial. Ann Emerg Med. 2011 May; 57(5):475-482.

9.     Kelley NE, Tepper DE. Rescue Therapy for Acute Migraine, Part 1: Triptans, Dihydroergotamine, and Magnesium. Headache. 2012 Jan; 52(1):114-128.

10.  Saadah HA. Abortive migraine therapy in the office with dexamethasone and prochlorperazine. Headache. 1994 Jan; 34(6):366-370.

11.  Karimi N, Tavakoli M, Charati JY, Shamisizade M. Single- dose intravenous sodium valproate (Depakine) versus dexamethasone for the treatment of acute migraine headache: a double-blind randomized clinical trial. Clin Exp Emerg Med. 2017 Sept; 4(3):138-145.

12.  Diphenhydramine. Lexi-Drugs. Lexi-Comp Online. Hudson, OH; 2018. Accessed April 8, 2018.

 13.  Goadsby PJ, Lipton RB, Ferrari MD. Migraine – Current Understanding and Treatment. N Engl J Med. 2002 Jan; 346(4):257-270.

14.  Allais G, De Lorenzo C, Quirico PE, Lupi G, Airola G, Mana O, et.al. Non-pharmacological approaches to chronic headaches: transcutaneous electrical nerve stimulation, lasertherapy, and acupuncture in transformed migraine treatment. Neuro Sci. 2003; 24:S138-S142.

 

 

 


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