IV meds For Migraine and Approach For Resistant Cases

Recent article found both regimens below equal efficacy:
prochlorperazine 10 mg and diphenhydranate 25 mg intravenously
metoclopramide 20 mg and diphenhydranate 25 mg intravenously
“Three quarters of subjects in both arms would want the same medication for their next migraine.”

Ann Emerg Med. 2008 Oct;52(4):399-406.
A randomized controlled trial of prochlorperazine versus metoclopramide for treatment of acute migraine. Friedman BW, Esses D, Solorzano C, Dua N, Greenwald P, Radulescu R, Chang E, Hochberg M, Campbell C, Aghera A, Valentin T, Paternoster J, Bijur P, Lipton RB, Gallagher EJ abstract

a drop of over 5/10 on VAS pain within one hour

In another article comparing IV prochlorperazine 10 mg vs.promethazine 25 mg “Prochlorperazine was superior to promethazine in the rate of headache reduction and rate of home drowsiness, with similar rates of akathesia, nausea resolution, patient satisfaction, and headache recurrence within 5 days of discharge.”:
Emerg Med. 2008 Oct;35(3):247-53. Epub 2008 Jun 5. Prochlorperazine vs. promethazine for headache treatment in the emergency department: a randomized controlled trial. Callan JE, Kostic MA, Bachrach EA, Rieg TS. abstract
Comment – now that I have used the 6 minute finger pressure technique (another blog article), I have been able to remit most generalized heaadaches.

I used to use Dihydroergotamine 0.5 – 1 mg pre-treated with metoclopramide 10 mg but nausea was still an issue (necessary for transformed headaches ,given every 8 hours x 1- 2 days, God help services availablitity for administering IV’s…) Never used 20 mg metoclopromide.

Another treatment that is popular is Sumatriptan 100 mg and sodium Naproxen (Anaprox) 500 mg., made more recent in the US as a Sumatriptan 85 mg – naproxen 500 mg combo tablet:

Expert Rev Neurother. 2008 Sep;8(9):1289-97. Sumatriptan/naproxen sodium combination for the treatment of migraine. Cleves C, Tepper SJ. abstract

Dexamethasone 4-8 mg IV (have to flush line with saline and give separately because precipitates with other agents) – was a good agent to help remit headaches and help with resistent cases. In this study they used 15 mg (huge! – I don’t think they use that much in brain edema):

Headache. 2008 Mar;48(3):333-40. Epub 2007 Nov 28.
Randomized controlled trial of intravenous dexamethasone to prevent relapse in acute migraine headache. Rowe BH, Colman I, Edmonds ML, Blitz S, Walker A, Wiens S. abstract

dropped VAS from 8 to 2 but they didn’t feel it helped prevent relapse in those not all better by discharge – maybe that is where the Kenalog 40-60 mg IM works – but unfortunately that takes 2-3 days.

I feel the left over headache would probably be coming from the neck; a recent article found cervical mobility restricted in people with episodic and transformed migraines suggesting it really is a player:

Headache. 2008 Sep 9. [Epub ahead of print] Cervical Mobility in Women With Migraine. Bevilaqua-Grossi D, Pegoretti KS, Goncalves MC, Speciali JG, Bordini CA, Bigal ME. abstract

“Contrasted to controls, individuals with episodic and TM [transformed migraines] have decreased cervical range of motion.”

I have found simple neck manual traction / myofascial release works very well for the residual pains in the emergency room: video of a version of that in Youtube here

When all else fails, I have added Toradol 30-60 mg IM.

A good review of migraine prophylaxis is here

These are those that feel resistent cases have triggers in the lower cervical spine and injection there would remit headaches:

Headache. 2006 Oct;46(9):1441-9.
Treatment of headaches in the ED with lower cervical intramuscular bupivacaine injections: a 1-year retrospective review of 417 patients. Mellick LB, McIlrath ST, Mellick GA abstract
(Our college does not like cervical spine injections done outside the hospital as at C5 right there is a radicular artery that will take the shot right to the spinal cord…)

I would be interested in any other approaches that works for resistant migraines.