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.)

·         Sumatriptan

·         Intranasal lidocaine

·         Intravenous Largactil (Chlorpromazine)

·         Intravenous lignocaine

Dihydoergotamine (D.H.E.)

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

abdominal pain/cramps
nausea/vomiting/diarrhea
leg weakness
dizziness
precordial distress
transient tachycardia or bradycardia
paresthesias, numbness and/or muscle pain in extremities
(may represent severe vasospasm)

D. Dose and administration

Neurology Service
1. Premedicate with antiemetic of choice (metoclopramide or prochlorperazine suggested).
2. Test dose of 0.5 mg IV push over 1 minute.
3. If test dose tolerated, 0.5 to 1 mg IV q8h.
4. Continue q8h dosing until headache improved, then q12h dosing for an additional two or three doses; continue antiemetic prn.
5. Recommended period of time for repetitive D.H.E. dosing is 48-72 hours.
6. D.H.E. may also be given SC or IM. These routes generally cause considerably less nausea then the IV route.
7. The SC dose of D.H.E. for home use is generally 1 mg q12h for approximately two weeks.
8. Total dose not to exceed 20 mg/week.

Emergency Department/Urgent Care Center
**all D.H.E. doses to be administered by ED resident or attending or UCC physician**

1. 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 minute.
2. If headache persists, repeat dose every 30 minutes until headache relief or total of 3 mg.
3. If no relief from a total of 2-3 mg D.H.E., consider narcotics.
4. If IV access is problematic, IM administration of above medications is acceptable.

E. Monitoring

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:

1. Discontinue further use of D.H.E.
2. Warm involved extremity.
3. Supportive care +/- vasodilator therapy (nitroglycerin, nitroprusside, papaverine, nifedipine, prazosin).

F. Dosage Form/Cost

1 mg/1 ml ampule of D.H.E. 45 $8.00/ampule (drug acquisition cost)

Sumatriptan

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.)

A. Contraindications

Absolute

·        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

Relative

·        patients at risk for coronary artery disease:

·        basilar or hemiplegic migraine

·        cerebral ischemia

·        cerebral hemorrorhage

·        geriatric patients

·        hepatic dysfunction

·        Raynaud’s 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

subcutaneous

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.

oral

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

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

1.Administer Normal Saline 500 ml IV over 15 min. (unless contraindicated by circulatory status)

2.Chlorpromazine ("Largactil") 10 mg IV (I st dose)

3.If attack does not begin to subside within 30 mins, repeat

chlorpromazine 10 mg IV (2nd dose)

4.If attack does not begin to subside within 30 mins, repeat - chlorpromazine 10 mg IV (3rd dose)

5.If 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.

Postural hypotension may be a problem.  Keep patient supine for at least 4 hours after last dose of chlorpromazine, and monitor BP every half hour.

Acute dystonic reactions may occur.  If so, treat with benztropine ("Cogentin") I mg im.

Intravenous Lignocaine Infusion

ONLY to be conducted on patients admitted under the Neurology Unit, on the specific order of the consultant on call.

1.    Indications

The primary indication is transformed migraine/rebound headache.  The treatment may occasionally be appropriate in severe and prolonged migraine resistant to other therapy.

Significant cardiac disease is a contra-indication.

2.   Procedure

This is an inpatient procedure.

Management 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.

3.   Observations during infusion

A 12 lead ECG should be obtained before and 30-60 minutes after starting the infusion.

Vital 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 minutes of  the infusion, then every 15 minutes for 3 hours, and thereafter every 2 hours while the patient is awake. 

The 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.

4.   General management during infusion

Full ward diet unless otherwise indicated.

The patient should generally rest in bed or chair, but may go to the toilet.  Showering should be supervised.