Template:Non-specific headache treatment: Difference between revisions
(Convert headache medications to MedicationDose templates for SMW integration)
 
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===Non-specific [[Headache]]===
===Non-specific [[Headache]]===
''If known, treat specific headache type; avoid [[opioid]] medications if at all possible''
''If known, treat specific headache type; avoid [[opioid]] medications if at all possible''
* 1st line: [[prochlorperazine]] (compazine) 10 mg IV (+/- [[diphenhydramine]] 25-50 mg IV) + 1 L [[IVF]] bolus
* 1st line: {{MedicationDose|drug=Prochlorperazine|dose=10 mg IV|route=IV|context=1st line headache abortive|indication={{PAGENAME}}|population=Adult}} (+/- {{MedicationDose|drug=Diphenhydramine|dose=25-50 mg IV|route=IV|context=Adjunct to prevent akathisia|indication={{PAGENAME}}|population=Adult}}) + 1 L [[IVF]] bolus
**Place prochlorperazine in IV bag to reduce chances of side effects from rapid administration
**Place prochlorperazine in IV bag to reduce chances of side effects from rapid administration
**Alternative [[metoclopramide]] 10 mg IV<ref>Metoclopramide for Pain and Nausea in Patients with Migraine. Am Fam Physician. 2005 May 1;71(9):1770.</ref> ([[diphenhydramine]] addition shows no clinical benifit<ref>Friedman BW, et al. Diphenhydramine as Adjuvant Therapy for Acute Migraine: An Emergency Department-Based Randomized Clinical Trial. Annals of EM. January 2016. 67(1):32-39.</ref>)
**Alternative {{MedicationDose|drug=Metoclopramide|dose=10 mg IV|route=IV|context=Alternative abortive|indication={{PAGENAME}}|population=Adult}}<ref>Metoclopramide for Pain and Nausea in Patients with Migraine. Am Fam Physician. 2005 May 1;71(9):1770.</ref> ([[diphenhydramine]] addition shows no clinical difference in effectiveness<ref>Friedman BW, Irizarry E, Solorzano C, et al. Randomized study of IV prochlorperazine plus diphenhydramine vs IV prochlorperazine alone for migraine in the ED. Neurology 2017;89:1-6</ref>)
*[[Acetaminophen]] IV or PO, 325-1000 mg
*[[Acetaminophen]] IV or PO, 325-1000 mg
* [[Ketorolac]] 10-30 mg IV (30-60mg IM)
* {{MedicationDose|drug=Ketorolac|dose=15-30 mg IV (30-60 mg IM)|route=IV/IM|context=NSAID for headache|indication={{PAGENAME}}|population=Adult}}
**Lower doses are shown to be just as effective<ref>Brown CR, Moodie JE, Wild VM, Bynum LJ. Comparison of intravenous ketorolac tromethamine and morphine sulfate in the treatment of postoperative pain. Pharmacotherapy. 1990;10(6Patient 2):116S-121S.</ref>
**Lower doses are shown to be just as effective<ref>Brown CR, Moodie JE, Wild VM, Bynum LJ. Comparison of intravenous ketorolac tromethamine and morphine sulfate in the treatment of postoperative pain. Pharmacotherapy. 1990;10(6Patient 2):116S-121S.</ref>
*[[Sumatriptan]] most effective within 6 hours of headache onset<ref>Efficacy and safety of intravenous acetylsalicylic acid lysinate compared to subcutaneous sumatriptan and parenteral placebo in the acute treatment of migraine. A double-blind, double-dummy, randomized, multicenter, parallel group study. The ASASUMAMIG Study Group. Diener HC. Cephalalgia. 1999 Jul; 19(6):581-8; discussion 542.</ref>
*{{MedicationDose|drug=Sumatriptan|dose=6 mg SC/IM (or 100 mg PO, or 1-2 sprays IN)|route=SC/IM/PO/IN|context=Triptan, most effective within 6h of onset|indication={{PAGENAME}}|population=Adult|notes=Max 12 mg SC/24h or 200 mg PO/24h}} <ref>Efficacy and safety of intravenous acetylsalicylic acid lysinate compared to subcutaneous sumatriptan and parenteral placebo in the acute treatment of migraine attacks. Cephalalgia. 1999;19(3):155-164.</ref>
**Serotonin 5HT1B/1D receptor agonist (e.g. [[sumatriptan]])
**Serotonin 5HT1B/1D receptor agonist (e.g. [[sumatriptan]])
**6 mg SQ or IM, may repeat dose x1 after 1 hour, max 12 mg / 24 hours
**6 mg SQ or IM, may repeat dose x1 after 1 hour, max 12 mg / 24 hours
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**OR 1-2 sprays IN (may repeat after 2 hours)
**OR 1-2 sprays IN (may repeat after 2 hours)
**Contraindications to triptans include CV disease, uncontrolled [[HTN]], [[pregnancy]]
**Contraindications to triptans include CV disease, uncontrolled [[HTN]], [[pregnancy]]
*[[Dexamethasone]] to prevent recurrence 48-72 hours post-ED discharge, if history of migraines and/or recurrent headaches<ref>Colman et al Parenteral dexamethasone for acute severe migraine headache: meta-analysis of randomised controlled trials for preventing recurrence. BMJ 2008 Jun.;336(7657):1359–1361</ref>
*{{MedicationDose|drug=Dexamethasone|dose=4-10 mg IV x1|route=IV|context=Prevent headache recurrence 48-72h post-discharge|indication={{PAGENAME}}|population=Adult}}<ref>Colman et al Parenteral dexamethasone for acute severe migraine headache: meta-analysis of RCTs for preventing relapse. BMJ. 2008;336(7657):1359-61</ref>
** 10 mg IV single dose is commonly accepted regimen, 4 mg IV dose was shown to be as efficacious in a follow up study. <ref>Friedman BW, Solorzano C, Kessler BD, Martorello K, Lutz CL, Feliciano C, Adler N, Moss H, Cain D, Irizarry E. Randomized Trial Comparing Low- vs High-Dose IV Dexamethasone for Patients With Moderate to Severe Migraine. Neurology. 2023 Oct 3;101(14):e1448-e1454.</ref>
** 10 mg IV single dose is commonly accepted regimen, 4 mg IV dose was shown to be as efficacious in a follow up study. <ref>Friedman BW, Solorzano C, Kessler BD, Martorello K, Lutz CL, Feliciano C, Adler N, Moss H, Cain D, Irizarry E. Randomized Trial Comparing Low- vs High-Dose IV Dexamethasone for Patients With Moderate to Severe Migraine. Neurology. 2023 Oct 3;101(14):e1448-e1454.</ref>


====Other 2nd and 3rd Line Options====
====Other 2nd and 3rd Line Options====
*[[Magnesium]] 1-2 g IV over 30-60 minutes, low side effect profile, in treatment of acute migraine attacks<ref>Demirkaya S et al. Efficacy of intravenous magnesium sulfate in the treatment of acute migraine attacks. Headache. 2001 Feb;41(2):171-7.</ref>
*{{MedicationDose|drug=Magnesium sulfate|dose=1-2 g IV over 30-60 min|route=IV|context=2nd/3rd line for acute headache|indication={{PAGENAME}}|population=Adult}}<ref>Demirkaya S et al. Efficacy of intravenous magnesium sulfate in the treatment of acute migraine attacks. Headache, 41 (2001), pp. 171-177</ref>
*[[Valproate]] sodium 500-1000 mg IV in 50 mL of NS over 20 minutes (alternatively 10 mg/kg IV, pediatrics, max 500 mg)<ref>Shahien R et al. Intravenous sodium valproate aborts migraine headaches rapidly. Acta Neurol Scand. 2011 Apr;123(4):257-65.</ref>
*{{MedicationDose|drug=Valproic acid|dose=500-1000 mg IV in 50 mL NS over 20 min (peds: 10 mg/kg, max 500 mg)|route=IV|context=2nd/3rd line for acute headache|indication={{PAGENAME}}|population=Adult|display=Valproate sodium}}<ref>Shahien R et al. Intravenous sodium valproate aborts migraine headaches rapidly. Acta Neurol Scand. 2011 Apr;123(4):257-65.</ref>
*[[Droperidol]] IV/IM 1.25-2.75 mg, plus or minus diphenhydramine for extrapyramidal symptoms<ref>Thomas MC et al. Droperidol for the treatment of acute migraine headaches. Ann Pharmacother. 2015 Feb;49(2):233-40.</ref>
*{{MedicationDose|drug=Droperidol|dose=1.25-2.75 mg IV or IM|route=IV/IM|context=2nd/3rd line for acute headache|indication={{PAGENAME}}|population=Adult|notes=Monitor EKG for QTc prolongation}}<ref>Thomas MC et al. Droperidol for the treatment of acute migraine headaches. Ann Pharmacother. 2015 Feb;49(2):233-40.</ref>
**Perform EKG monitoring for patients at risk of QTc prolongation
**Perform EKG monitoring for patients at risk of QTc prolongation
**Do not give to patients who take already multiple QT prolonging drugs
**Do not give to patients who take already multiple QT prolonging drugs

Latest revision as of 22:34, 20 March 2026

Non-specific Headache

If known, treat specific headache type; avoid opioid medications if at all possible

  • 1st line: Prochlorperazine 10 mg IV IV (+/- Diphenhydramine 25-50 mg IV IV) + 1 L IVF bolus
    • Place prochlorperazine in IV bag to reduce chances of side effects from rapid administration
    • Alternative Metoclopramide 10 mg IV IV[1] (diphenhydramine addition shows no clinical difference in effectiveness[2])
  • Acetaminophen IV or PO, 325-1000 mg
  • Ketorolac 15-30 mg IV (30-60 mg IM) IV/IM
    • Lower doses are shown to be just as effective[3]
  • Sumatriptan 6 mg SC/IM (or 100 mg PO, or 1-2 sprays IN) SC/IM/PO/IN — Max 12 mg SC/24h or 200 mg PO/24h [4]
    • Serotonin 5HT1B/1D receptor agonist (e.g. sumatriptan)
    • 6 mg SQ or IM, may repeat dose x1 after 1 hour, max 12 mg / 24 hours
    • OR 100 mg PO, may repeat dose x1 after 2 hours, max 200 mg / 24 hours
    • OR 1-2 sprays IN (may repeat after 2 hours)
    • Contraindications to triptans include CV disease, uncontrolled HTN, pregnancy
  • Dexamethasone 4-10 mg IV x1 IV[5]
    • 10 mg IV single dose is commonly accepted regimen, 4 mg IV dose was shown to be as efficacious in a follow up study. [6]

Other 2nd and 3rd Line Options

  • Magnesium sulfate 1-2 g IV over 30-60 min IV[7]
  • Valproate sodium 500-1000 mg IV in 50 mL NS over 20 min (peds: 10 mg/kg, max 500 mg) IV[8]
  • Droperidol 1.25-2.75 mg IV or IM IV/IM — Monitor EKG for QTc prolongation[9]
    • Perform EKG monitoring for patients at risk of QTc prolongation
    • Do not give to patients who take already multiple QT prolonging drugs
  • Consider haloperidol IV 5 mg in IVF bolus with diphenhydramine to prevent need for rescue medications[10]
  • Consider 5-10 mg PO olanzapine (Zyprexa, Zydis) for prochlorperazine allergy[11][12]
    • Particularly useful in psych patients with mania, BPD, psychosis
    • IV olanzapine may be as safe or safer than IM, with faster onset[13]
  • Ketamine IM/IV at subdissociative dosages, with risk stratification for potential ICP increase, though now widely considered a myth[14]
  • Cervical spine injection with IM injection of 1.5 mL of 0.5% bupivacaine (plus or minus methylprednisolone acetate) bilaterally to the sixth or seventh spinous process[15]
  • Sphenopalatine ganglion block
    • Great for patients without an IV
    • 10 cm cotton-tipped applicator soaked in lidocaine or bupivicaine and inserted nasally along the superior border of the middle turbinate and left for 5-10 minutes [16]
  • Consider greater occipital nerve block
    • For refractory occipital migraine, cluster headache, occipital neuralgia, cervicogenic headache, or migraine with occipital nerve irritation or tenderness [17]
  • Severe, intractable status migrainosus may benefit from off-label IV propofol[18][19][20]
    • Requires procedural sedation monitoring and possible IV fluid resuscitation, respiratory decompensation intervention
    • Propofol 0.5 mg/kg bolus, then 0.25 mg/kg every 10 minutes for 1 hour
    • Less aggressive regimens include propofol 10 mg q5-10 min to ma of 80 mg[21]
    • Consider using 1 mL 2% lidocaine added to every 10 mL of 10 mg/mL concentration propofol
    • Average dosage required ~100-125 mg
  1. ↑ Metoclopramide for Pain and Nausea in Patients with Migraine. Am Fam Physician. 2005 May 1;71(9):1770.
  2. ↑ Friedman BW, Irizarry E, Solorzano C, et al. Randomized study of IV prochlorperazine plus diphenhydramine vs IV prochlorperazine alone for migraine in the ED. Neurology 2017;89:1-6
  3. ↑ Brown CR, Moodie JE, Wild VM, Bynum LJ. Comparison of intravenous ketorolac tromethamine and morphine sulfate in the treatment of postoperative pain. Pharmacotherapy. 1990;10(6Patient 2):116S-121S.
  4. ↑ Efficacy and safety of intravenous acetylsalicylic acid lysinate compared to subcutaneous sumatriptan and parenteral placebo in the acute treatment of migraine attacks. Cephalalgia. 1999;19(3):155-164.
  5. ↑ Colman et al Parenteral dexamethasone for acute severe migraine headache: meta-analysis of RCTs for preventing relapse. BMJ. 2008;336(7657):1359-61
  6. ↑ Friedman BW, Solorzano C, Kessler BD, Martorello K, Lutz CL, Feliciano C, Adler N, Moss H, Cain D, Irizarry E. Randomized Trial Comparing Low- vs High-Dose IV Dexamethasone for Patients With Moderate to Severe Migraine. Neurology. 2023 Oct 3;101(14):e1448-e1454.
  7. ↑ Demirkaya S et al. Efficacy of intravenous magnesium sulfate in the treatment of acute migraine attacks. Headache, 41 (2001), pp. 171-177
  8. ↑ Shahien R et al. Intravenous sodium valproate aborts migraine headaches rapidly. Acta Neurol Scand. 2011 Apr;123(4):257-65.
  9. ↑ Thomas MC et al. Droperidol for the treatment of acute migraine headaches. Ann Pharmacother. 2015 Feb;49(2):233-40.
  10. ↑ Gaffigan ME et al. A Randomized Controlled Trial of Intravenous Haloperidol vs. Intravenous Metoclopramide for Acute Migraine Therapy in the Emergency Department. J Emerg Med. 2015 Sep;49(3):326-34.
  11. ↑ Silberstein SD et al. Olanzapine in the treatment of refractory migraine and chronic daily headache. Headache. 2002 Jun;42(6):515-8.
  12. ↑ Rozen TD. Olanzapine as an abortive agent for cluster headache. Headache. 2001;41(8):813-816.
  13. ↑ Farkas J. PulmCrit. PulmCrit- Intravenous olanzapine: Faster than IM olanzapine, safer than IV haloperidol? Feb 1, 2016. http://emcrit.org/pulmcrit/intravenous-olanzapine-haloperidol/
  14. ↑ Sin B et al. The use of subdissociative-dose ketamine for acute pain in the emergency department. Acad Emerg Med. 2015 Mar;22(3):251-7.
  15. ↑ Mellick LB et al. Treatment of headaches in the ED with lower cervical intramuscular bupivacaine injections: a 1-year retrospective review of 417 patients. Headache. 2006 Oct;46(9):1441-9.
  16. ↑ https://www.aliem.com/2017/03/trick-sphenopalatine-ganglion-block-primary-headaches/
  17. ↑ https://www.nuemblog.com/blog/occipital-nerve-block
  18. ↑ The Efficacy of Propofol vs. Subcutaneous Sumatriptan for Treatment of Acute Migraine Headaches in the Emergency Department: A DBCT. Pain Prac. 2014 Jul 12.
  19. ↑ Fortuitous Finding – IV Propofol: Unique Effectiveness in Treating Intractable Migraine. Krusz, John C. Headache 2000;40:224-230.
  20. ↑ Simmonds MK. The effect of single-dose porpofol injection on pain and quality of life in chronic daily headaches: a RDBCT. Anesth Analg. 2009 3Dec;109(6):1972-80.
  21. ↑ Soleimanpour et al. BMC Neurology 2012. 12:114. 90 pts in ED w/ Migraine.
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