UMEM Educational Pearls

Title: Status what?! - Conquering Migraines

Category: Neurology

Keywords: migraine, headache, opioids, dopamine antagonist (PubMed Search)

Posted: 8/26/2015 by Danya Khoujah, MBBS
Click here to contact Danya Khoujah, MBBS

Status migrainosus is a migraine that lasts more than 72 hours, and can be rather challenging to control. A few tips to tackle this are:

1. Adequately hydrate all patients (IV fluids are usually required, especially with severe nausea/vomiting)

2. Establish realistic expectations for the patient. A patient with chronic daily headaches will not be pain-free in the ED.

3. Use IV nonopioid medications for pain control

1^st Line:

- Dopamine Antagonists: in increasing efficacy

- Metoclopramide

- Phenothiazines: prochlorperazine, promethazine and chlorpromazine

- Butyrophenones: droperidol and haloperidol

- NSAIDs: such as Ketorolac IV or IM

2^nd Line:

- Corticosteroids: Do not treat the migraine in the ED, but prevent headache recurrence within 72 hours.

- Magnesium Sulfate: Has shown mixed efficacy. More likely to have a sustained benefit in patient with serum magnesium level of 1.3mg/dL or less.

- Valrpoic Acid: Be careful of combining it with Topiramate.

- Vasoconstrictors: Triptans, ergotamine, dihydroergotamine. Effective, but use is limited by contraindications.

- Opioids: Last resort