Pharmacology Rounds – What Works for Acute Migraine

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Nurses Edition Commentary

Lisa Chavez, RN and Kathy Garvin, RN

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John C., P.A. -

In your "Pharmacology Rounds – What Works for Acute Migraine" segment, I was surprised you didn't mention using lidocaine or marcaine to do a sphenopalantine ganglion block.
I have been doing this now for about 4 months and have tried it 16 times. It was completely successful bringing Pain down from 8, 9 or 10 out of 10 in eleven out of fourteen headaches which I considered to be true or pure migraines or cluster headaches.
I tried it on a post concussion headache without results and on what I thought was a migraine brought on by an infectious illness (Pt had sore throat and fever) also without good relief.
Of the fourteen what I will call true migraines, I could not get the swabs to the back of the nasopharnyx in two (although I think it was lack of experience and I would be able to now) and the remaining patient who did not experience complete relief stated she had two different headaches, a 10/10 right sided headache which was typical of her migraines and a 7/10 occipital headache. She described the 10/10 right sided went to 0/10 and the 7/10 occipital headache went to a 5/10.
I wonder if you could do a segment on this technique?

John Cunningham, MPAS, CCPA
Emergency Physician Assistant
Guelph, Ontario, Canada

Bryan H. -

John, thanks for your comments. This segment was specifically reviewing a new guideline that was published on management of migraines in the ED. The block you describe was not addressed in the guideline. From what I have seen, it seems to have more data in the chronic management of migraines or other types of headache. Thanks for sharing your experience. We'll add it to the list of potential topics to discuss in future episodes.

David N., M.D. -

Just listened to segment on migraine headaches. Excellent. I have a question. My migraine cocktail is IV Ketorolac, Reglan, Benadryl and sometimes Decadron. I like the idea of having Haloperidol as a fallback for refractory pain. My question is: once Reglan has been given and is on-board, is it safe to then give Haloperidol?

Dave Nidorf
ER Physician
New Paltz, NY

Bryan H. -

Dr. Nidorf, this is an excellent question. In most drug references, the combination of metoclopramide + haloperidol is contraindicated. The risk of one-time doses of both of these drugs causing severe EPS or NMS is low. The therapeutic duration of action of IV metoclopramide is only about 2 hours. So, if it's been a few hours since the metoclopramide dose, the risk of an interaction with haloperidol is a bit lower. Many like to try a round of prochlorperazine if metoclopramide has failed. Ironically, this combination carries the same contraindication as haloperidol + metoclopramide. In summary, there is a risk of interaction, but it is low and decreases with time after the initial dose of metoclopramide.

William M. -

I was talking to a colleague about your segment and he told me that he has augmented the standard headache cocktail with 1000 mg Keppra for migraines refractory to standard metoclopramide/dexamethasone/ketorolac treatment. He said it was successful in 2/2 cases. Is there any merit to this? I have not seen this mentioned in any materials I studied.

Bryan H. -

Hi William, thanks for the note. From the literature reviews that I've done, there are scant trials on levetiracetam in migraine management. The few available are for prophylaxis or chronic migraine treatment. The guideline we reviewed for the EM:RAP segment didn't comment on levetiracetam. Perhaps will see more data in the future that will apply to acute management.

Alonso M. -

Hey guys!

About the steroids... it was my understanding that they should be offered in patients suffering of a prolonged migraine i.e. Status Migrainosus, and not everyone.
Do you use it routinely?

Other thing is... what are your thoughts on Chlorpromazine? I use it as a third line agent and has worked every time!

Great segment!
Saludos desde Chile!

Bryan H. -

Thanks for the great comments! We specifically reviewed a recent guideline for management of migraines in the ED. Rob and I talked to a few folks and not many had been using dexamethasone. The data seems to support its use in acute attacks to prevent early recurrence. It still isn't standard practice at my current institution, but the benefit may outweigh risk. Chlorpromazine is recommended by the guideline as 'may offer' with 'possible/likely benefit.' We prefer prochlorperazine as our phenothiazine, but you could substitute in chlorpromazine if that's what you have available. There probably isn't any benefit in using chlorpromazine if prochlorperazine was already given (it also raises the risk of adverse events).

Marc G. -

quick question about post LP headache. My ARNP called anesthesia for a blood patch as a first line and then asked me about their lack of enthusiasm about treating this patient initially. I suggested the old standbys as above as well as caffeine IV and maybe depacon. He printed an article for me from UTD stating this doesn't work. Any insights?

Bryan H. -

Hi Marc, in my experience, the first-line therapy is institution-specific. Even though the data on caffeine is not great, (at many places) it's much easier to give rather than arranging blood patches. I have not seen any published data on valproic acid for this indication. Either PO or IV caffeine can be tried. PO gabapentin, IV hydrocortisone, PO theophylline, and subcut sumatriptan are the other therapies that have at least one published article related to their use in post-LP headaches.

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