Treatment of Migraine Headache
05 November 2004
The following is a guide for treating migraine headache unresponsive to first line agents (NSAIDs including ASA, acetaminophen, antiemetics, caffeine, ergotamine tartrate, propoxyphene, butalbital, various OTC preparations). Use of the following agents will be detailed:
∑ Dihydroergotamine (D.H.E.)
∑ Intranasal lidocaine
∑ Intravenous Largactil (Chlorpromazine)
∑ Intravenous lignocaine
Clinically, D.H.E. headaches been proven to be highly effective in treating acute migraine, with or without aura, and may be administered at any time during an attack, including the aura.
**Use limited to patients with intractable migraine headache who headache failed other therapies. Use also limited to Neurology Service and Emergency Department/Urgent Care Center.**
A. Cautions and Contraindications
B. Drug interactions
C. Adverse effects
D. Dose and administration
Department/Urgent Care Center
Administer antiemetic of choice (metoclopramide or prochlorperazine suggested);
wait 60 minutes; if headache persists administer 0.5-1 mg D.H.E. IV push over 1
Monitor vital signs at baseline and within 5 minutes of each D.H.E. dose.
Vasospasm (as described in section C) may also lead to symptoms such as coldness, mottling, pallor, cyanosis, decreased or absent peripheral pulses and rarely, severe ischemia/necrosis. If vasospasm occurs:
Discontinue further use of D.H.E.
F. Dosage Form/Cost
1 mg/1 ml ampule of D.H.E. 45 $8.00/ampule (drug acquisition cost)
Effective in 80% of patients within 2 hrs of SC administration. Headache recurs in up to 40% of patients within 24-48 hrs at which time a second dose may be given.
∑ A clear diagnosis of intractable acute migraine headaches been established
∑ First line agents have failed (e.g. NSAIDs, antiemetics, acetaminophen, etc.)
∑ IV route due to potential for coronary vasospasm
∑ ischemic heart disease
∑ uncontrolled hypertension
∑ concomitant use of MAO inhibitors or within 2 wks of discontinuing MAO inhibitor
∑ concurrent ergotamine-containing drugs (risk of prolonged vasospastic reactions)
∑ hypersensitivity to sumatriptan
∑ patients at risk for coronary artery disease:
∑ basilar or hemiplegic migraine
∑ cerebral ischemia
∑ cerebral hemorrorhage
∑ geriatric patients
∑ hepatic dysfunction
∑ Raynaudís disease
B. Adverse effects ( > 5 % incidence)
C. Drug interactions
∑ ergot-containing drugs and MAO inhibitors as described under contraindications
∑ concomitant use of selective serotonin - reuptake inhibitors (fluoxetine, paroxetine, sertraline, fluvoxamine) and sumatriptan has been reported to cause weakness, hyperreflexia, and incoordination as well as an increase in frequency of migraine attacks and decrease in effectiveness of sumatriptan
D. Dose and administration
1. 6 mg SC x 1
2. If no effect after 1 hr, a second dose SHOULD NOT be given.
3. If initial response is achieved and headache recurs within 24-48 hrs, a second dose may be given.
4. Not to exceed 12 mg in 24 hrs.
1. In patients without significant vomiting, administer a single dose of 25 mg.
2. If a satisfactory headache response has not been achieved after two hours, a second dose of up to 100 mg may be given (controlled trials have not examined the efficacy of a second dose if an initial dose of 25 mg is ineffective)
3. If headache returns, additional oral doses may be given in intervals of at least two hours up to a 24 hour maximum of 300 mg.
E. Dosage Form/Cost (Drug Acquisition)
Intranasal lidocaine has been shown to provide relief in approximately 55% of patients with moderate or severe migraine (JAMA 1996;276:319-321). It is contraindicated in patients allergic to lidocaine or in patients at risk for aspiration. The technique used in this study is detailed below:
1. Draw up 1 ml of 4% topical lidocaine solution in a syringe.
2. Have a patient lie supine with the head hyperextended 45 degrees and rotated 30 degrees to the side of headache.
3. Drip 0.5 ml of solution over 30 seconds into nostril on side of headache; if headache is bilateral, repeat procedure with other nostril.
4. If after 2 minutes, the headache persists with a rating > 2 on the 10-point scale*, a second dose may be instilled in the same manner.
* 10 point scale (Headache Rating)
Intravenous Largactil Infusion
Normal Saline 500 ml IV over 15 min. (unless contraindicated by circulatory
("Largactil") 10 mg IV (I st dose)
attack does not begin to subside within 30 mins, repeat
10 mg IV (2nd dose)
attack does not begin to subside within 30 mins, repeat - chlorpromazine 10 mg
IV (3rd dose)
attack does not begin to subside after a further 30 mins after the 3rd dose,
consult Neurology Unit and consider DHE protocol for resistant acute attack if
at least 12 hours has passed since last dose of sumatriptan.
hypotension may be a problem. Keep
patient supine for at least 4 hours after last dose of chlorpromazine, and
monitor BP every half hour.
dystonic reactions may occur. If
so, treat with benztropine ("Cogentin") I mg im.
to be conducted on patients admitted under the Neurology Unit, on the specific
order of the consultant on call.
primary indication is transformed migraine/rebound headache.
The treatment may occasionally be appropriate in severe and prolonged
migraine resistant to other therapy.
cardiac disease is a contra-indication.
is an inpatient procedure.
of such a case by the Neurology Unit is recommended.
Medical assessment and examination is required before commencing the infusion. Infusion must be delivered at a controlled rate by I.M.E.D. pump or similar device. The usual dose of lignocaine is 2 mg/min.
Observations during infusion
12 lead ECG should be obtained before and 30-60 minutes after starting the
signs (pulse, blood pressure, respiratory rate, temperature) should be recorded
prior to infusion. Pulse and blood
pressure should be measured every 5 minutes for the first 30
patient should be attached to a bedside cardiac monitor.
ECG rhythm strips should be obtained every 5 minutes for the first 30 minutes of the infusion, then every 15 minutes for 3 hours, and thereafter every 2 hours, including sleep.
General management during infusion
ward diet unless otherwise indicated.
patient should generally rest in bed or chair, but may go to the toilet.
Showering should be supervised.