|
| |
| Symptomatic Treatment |
 | Mild attacks
 | Buffered aspirin (not enteric coated) 650-1300 mg q 4h × 2 |
| Ibuprofen 400-800 mg q6h × 2 |
| Naproxen sodium 500-1000 mg PO |
| Adjunctive medication: Metoclopramide10 mg PO or IV |
| Combination Analgesics |
|
|
| Moderate Attack
|
|
| Severe Attacks
| Butorphanol (Stadol): 1 spray (1 mg) in 1 nostril, may repeat
once in 3-5 h. |
| Chlorpromazine: 50 mg IM; or 0.1 mg/kg IV by drip over 20 min, repeated
after 15 min (maximum 37.5 mg); pretreat with normal saline IV. May cause drowsiness,
extrapyramidal reactions. |
| Dexamethasone: 12-20 mg IV in resistant case. |
| DHE: see above or see table |
| Ketorolac: 30-60 mg IM, maximum 120 mg/ 24 h |
| Narcotic analgesics:
see table |
| Metoclopramide: 10 mg IV (if not effective within 20 min follow
with 0.5-1 mg of DHE IV, repeat up to 2 mg over 3 h) |
| Triptans -5 -HT1 receptor
agonist |
|
|
| Ultra-severe attacks or prolonged attacks.
| General principles same as those for severe attacks. |
| Patients who are vomiting may need to be rehydrated. |
| DHE is the drug of choice, may need to give 0.51.0 mg IV every 8 hours
for 24 hours or more, with each dose preceded by 10 mg of metoclopramide. Appropriate use of DHE -
AMA headache resource center. |
| Addition of promethazine 50 mg IM, chlorpromazine 50 mg IM has been
recommended. |
| Other recommended medications, given alone or in combination, include the
following:
 | Prochlorperazine (10 mg intravenously) plus diphenhydramine (10 mg
intravenously every 4 to 6 hours as needed) until symptoms are relieved |
| Chlorpromazine 10.012.5 mg [0.1 mg/kg] intravenously following an
intravenous 500-mL bolus of normal saline. |
| Dexamethasone 820 mg IM or IV or methylprednisolone 100250 mg IV |
| Dexamethasone 8 mg IM plus meperidine 75100 mg plus promethazine 50 mg
IM. |
|
|
|
| Special situations
| Early nausea or difficulty taking tablets
| Zolmitriptan (Zomig) 5 mg nasal spray |
| Sumatriptan (Imitrex) 20 mg nasal spray |
| Rizatriptan (Maxalt) 10 mg MLT wafer |
| Zolmitriptan (Zomig) 2.5 mg ZMT wafer |
|
| Headache recurrence
| Ergotamine 1- 2 mg |
| Eletriptan (Relpax) 80 mg |
| Naratriptan 2.5 mg po |
| Dihydroergotamine 1 mg IM |
|
| Early vomiting or rapid progression migraine
| Sumatriptan 6 mg SC |
| Dihydroergatamine 1 mg IM |
|
|
|
|
|
Ergotamines
do not use in patient with Coronary arterial disease,
peripheral vascular disease, uncontrolled
hypertension |
| DHE 45 injection |
| 1mg/amp |
| Dose: 0.5 to 1 mg IM, SC, IV may repeat at 1 hour, up to 3 mg/day |
| Side effect Chest tightness, tingling, nausea. ( similar to those of
triptan except that DHE has a greater tendency to cause nausea and is less likely to
induce chest pain) |
|
DHE nasal spray
(Migranal) |
| 1 spray to nostril, may repeat every 15 min up to
total of 4 doses. 4 spray per amp. |
| Cost: $120 for 4 amp |
|
Ergotamine + caffeine
(Cafergot) |
| tab: 1mg/100 mg |
| Cost about $1 per tab. |
| suppository: 2 mg/100mg |
| dose: 1 to 2 at onset, then 1 tab q half hr, max 6 tab |
|
Ergotamine
(Ergostat) |
tab: 2 mg ( may be hard to find)
dose: 1 tab SL q half hr, max 3 tab/day |
|
|
| Combination Analgesics |
| Fioricet, Esgic |
| Butabital 50mg/ caffeine 40 mg/ acetaminophen 325 mg |
| Dose: 1 to 2 tab q6 prn |
| Butabital is potentially habit forming |
|
| Fiorinal |
| Butabital 50mg/ caffeine 40mg/ aspirin 325mg |
| Dose: 1 to 2 tab q6 prn |
| Butabital is potentially habit forming |
| Aspirin may have GI side effect. |
|
| Midrin |
| Isometheptene 65 mg+ Dichloralphenazone 100 mg +
Acetaminophen 325 mg |
| Dose: 1 cap at onset, then q 1 hr, max 6 cap/d or
10cap/wk |
| Avoid in CAD, HTN, PVD |
|
|
|
| Other treatments |
| Butorphanol (Stadol Nasal spray) |
| 1 bottle: 15 sprays |
| Dose: 1 mg per spray, 1 spray to each nostril, may repeat q4 hr prn |
| Potentially habit forming |
|
| Lidocaine (Xylocaine) |
| 4% Lidocaine solution to cotton wick apply to ipsilateral nose |
| Patient will lie supine |
|
| Magnesium Sulphate? |
|
Headache index page
|
