Template:Non-specific headache treatment: Difference between revisions
Spenceemmett (talk | contribs) |
|||
(14 intermediate revisions by 6 users not shown) | |||
Line 1: | Line 1: | ||
===Non-specific [[Headache]]=== | ===Non-specific [[Headache]]=== | ||
'' | ''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 | * 1st line: [[prochlorperazine]] (compazine) 10 mg IV (+/- [[diphenhydramine]] 25-50 mg IV) + 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 [[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>) | ||
*[[Acetaminophen]] IV or PO, 325-1000 mg | *[[Acetaminophen]] IV or PO, 325-1000 mg | ||
* [[Ketorolac]] 30 mg IV | * [[Ketorolac]] 10-30 mg IV (30-60mg IM) | ||
**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> | |||
**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 | |||
**Contraindications to triptans include CV disease, uncontrolled [[HTN]], [[pregnancy]] | |||
*Consider [[dexamethasone]] 10 mg IV single dose to prevent recurrence 48-72 hrs post-ED discharge, if history of recurrent headaches<ref>Colman et al Paraenteral dexamethasone for acute severe migraine headache: meta-analysis of randomised controlled trials for preventing recurrence. BMJ 2008 Jun.;336(7657):1359–1361</ref> | *Consider [[dexamethasone]] 10 mg IV single dose to prevent recurrence 48-72 hrs post-ED discharge, if history of recurrent headaches<ref>Colman et al Paraenteral dexamethasone for acute severe migraine headache: meta-analysis of randomised controlled trials for preventing recurrence. BMJ 2008 Jun.;336(7657):1359–1361</ref> | ||
====Other 2nd and 3rd Line | ====Other 2nd and 3rd Line Options==== | ||
*Magnesium 1 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> | *[[Magnesium]] 1 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> | ||
*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> | *[[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> | ||
*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> | *[[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> | ||
**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 | ||
*Consider haloperidol IV 5 mg in IVF bolus with diphenhydramine to prevent need for rescue medications<ref>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.</ref> | *Consider [[haloperidol]] IV 5 mg in IVF bolus with [[diphenhydramine]] to prevent need for rescue medications<ref>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.</ref> | ||
*Consider 5-10 mg PO [[olanzapine]] (Zyprexa, Zydis) for prochlorperazine allergy<ref>Silberstein SD et al. Olanzapine in the treatment of refractory migraine and chronic daily headache. Headache. 2002 Jun;42(6):515-8.</ref><ref>Rozen TD. Olanzapine as an abortive agent for cluster headache. Headache. 2001;41(8):813-816.</ref> | *Consider 5-10 mg PO [[olanzapine]] (Zyprexa, Zydis) for prochlorperazine allergy<ref>Silberstein SD et al. Olanzapine in the treatment of refractory migraine and chronic daily headache. Headache. 2002 Jun;42(6):515-8.</ref><ref>Rozen TD. Olanzapine as an abortive agent for cluster headache. Headache. 2001;41(8):813-816.</ref> | ||
**Particularly useful in psych patients with mania, BPD, psychosis | **Particularly useful in psych patients with mania, BPD, psychosis | ||
**IV olanzapine may be as safe or safer than IM, with faster onset<ref>Farkas J. PulmCrit. PulmCrit- Intravenous olanzapine: Faster than IM olanzapine, safer than IV haloperidol? Feb 1, 2016. http://emcrit.org/pulmcrit/intravenous-olanzapine-haloperidol/</ref> | **IV olanzapine may be as safe or safer than IM, with faster onset<ref>Farkas J. PulmCrit. PulmCrit- Intravenous olanzapine: Faster than IM olanzapine, safer than IV haloperidol? Feb 1, 2016. http://emcrit.org/pulmcrit/intravenous-olanzapine-haloperidol/</ref> | ||
*[[Ketamine]] IM/IV at subdissociative dosages, with risk stratification for potential ICP increase, though now widely considered a myth<ref>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.</ref> | *[[Ketamine]] IM/IV at subdissociative dosages, with risk stratification for potential ICP increase, though now widely considered a myth<ref>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.</ref> | ||
*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<ref>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.</ref> | |||
*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<ref>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.</ref> | *Sphenopalatine ganglion block | ||
*Severe, intractable status migrainosus may benefit from off-label IV propofol<ref>The Efficacy of Propofol vs. Subcutaneous Sumatriptan for Treatment of Acute Migraine Headaches in the Emergency Department: A DBCT. Pain Prac. 2014 Jul 12.</ref><ref>Fortuitous Finding – IV Propofol: Unique Effectiveness in Treating Intractable Migraine. Krusz, John C. Headache 2000;40:224-230.</ref><ref>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.</ref> | **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 <ref>https://www.aliem.com/2017/03/trick-sphenopalatine-ganglion-block-primary-headaches/</ref> | |||
*Consider [[greater occipital nerve block]] | |||
**For refractory occipital migraine, cluster headache, occipital neuralgia, cervicogenic headache, or migraine with occipital nerve irritation or tenderness <ref>https://www.nuemblog.com/blog/occipital-nerve-block</ref> | |||
*Severe, intractable status migrainosus may benefit from off-label IV [[propofol]]<ref>The Efficacy of Propofol vs. Subcutaneous Sumatriptan for Treatment of Acute Migraine Headaches in the Emergency Department: A DBCT. Pain Prac. 2014 Jul 12.</ref><ref>Fortuitous Finding – IV Propofol: Unique Effectiveness in Treating Intractable Migraine. Krusz, John C. Headache 2000;40:224-230.</ref><ref>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.</ref> | |||
**Requires procedural sedation monitoring and possible IV fluid resuscitation, respiratory decompensation intervention | **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 | **Propofol 0.5 mg/kg bolus, then 0.25 mg/kg every 10 minutes for 1 hour |
Revision as of 03:02, 11 August 2021
Non-specific Headache
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
- Place prochlorperazine in IV bag to reduce chances of side effects from rapid administration
- Alternative metoclopramide 10 mg IV[1] (diphenhydramine addition shows no clinical benifit[2])
- Acetaminophen IV or PO, 325-1000 mg
- Ketorolac 10-30 mg IV (30-60mg IM)
- Lower doses are shown to be just as effective[3]
- Sumatriptan most effective within 6 hours of headache onset[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
- Contraindications to triptans include CV disease, uncontrolled HTN, pregnancy
- Consider dexamethasone 10 mg IV single dose to prevent recurrence 48-72 hrs post-ED discharge, if history of recurrent headaches[5]
Other 2nd and 3rd Line Options
- Magnesium 1 g IV over 30-60 minutes, low side effect profile, in treatment of acute migraine attacks[6]
- Valproate sodium 500-1000 mg IV in 50 mL of NS over 20 minutes (alternatively 10 mg/kg IV, pediatrics, max 500 mg)[7]
- Droperidol IV/IM 1.25-2.75 mg, plus or minus diphenhydramine for extrapyramidal symptoms[8]
- 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[9]
- Consider 5-10 mg PO olanzapine (Zyprexa, Zydis) for prochlorperazine allergy[10][11]
- Particularly useful in psych patients with mania, BPD, psychosis
- IV olanzapine may be as safe or safer than IM, with faster onset[12]
- Ketamine IM/IV at subdissociative dosages, with risk stratification for potential ICP increase, though now widely considered a myth[13]
- 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[14]
- 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 [15]
- Consider greater occipital nerve block
- For refractory occipital migraine, cluster headache, occipital neuralgia, cervicogenic headache, or migraine with occipital nerve irritation or tenderness [16]
- Severe, intractable status migrainosus may benefit from off-label IV propofol[17][18][19]
- 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[20]
- Consider using 1 mL 2% lidocaine added to every 10 mL of 10 mg/mL concentration propofol
- Average dosage required ~100-125 mg
- ↑ Metoclopramide for Pain and Nausea in Patients with Migraine. Am Fam Physician. 2005 May 1;71(9):1770.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ Colman et al Paraenteral dexamethasone for acute severe migraine headache: meta-analysis of randomised controlled trials for preventing recurrence. BMJ 2008 Jun.;336(7657):1359–1361
- ↑ Demirkaya S et al. Efficacy of intravenous magnesium sulfate in the treatment of acute migraine attacks. Headache. 2001 Feb;41(2):171-7.
- ↑ Shahien R et al. Intravenous sodium valproate aborts migraine headaches rapidly. Acta Neurol Scand. 2011 Apr;123(4):257-65.
- ↑ Thomas MC et al. Droperidol for the treatment of acute migraine headaches. Ann Pharmacother. 2015 Feb;49(2):233-40.
- ↑ 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.
- ↑ Silberstein SD et al. Olanzapine in the treatment of refractory migraine and chronic daily headache. Headache. 2002 Jun;42(6):515-8.
- ↑ Rozen TD. Olanzapine as an abortive agent for cluster headache. Headache. 2001;41(8):813-816.
- ↑ Farkas J. PulmCrit. PulmCrit- Intravenous olanzapine: Faster than IM olanzapine, safer than IV haloperidol? Feb 1, 2016. http://emcrit.org/pulmcrit/intravenous-olanzapine-haloperidol/
- ↑ 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.
- ↑ 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.
- ↑ https://www.aliem.com/2017/03/trick-sphenopalatine-ganglion-block-primary-headaches/
- ↑ https://www.nuemblog.com/blog/occipital-nerve-block
- ↑ The Efficacy of Propofol vs. Subcutaneous Sumatriptan for Treatment of Acute Migraine Headaches in the Emergency Department: A DBCT. Pain Prac. 2014 Jul 12.
- ↑ Fortuitous Finding – IV Propofol: Unique Effectiveness in Treating Intractable Migraine. Krusz, John C. Headache 2000;40:224-230.
- ↑ 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.
- ↑ Soleimanpour et al. BMC Neurology 2012. 12:114. 90 pts in ED w/ Migraine.