Recurrent migraine sufferers managed in the community should be managed with a combination of Abortive, Rescue and Prophylactic medications for their attacks.
If the correct dose and agent is taken at the onset of migraine the migraine can be completely aborted or substantially attenuated. The time to take the abortive treatment is at the time of onset of the preceding migraine aura; if no aura then at the onset of headache. First line options include high dose fast acting oral NSAIDS (eg ibuprofen 600-800mg). For those who typically have assoc nausea the addition of metoclopromide 10mg may be useful although its oral bioavailability is quite variable between patients, so if ineffective consider other anti-emetics (eg sublingual ondansetron).
Paracetamol +/- codeine are frequently used and many patients find the combinations that include a drowsy antihistamine valuable due to its sleep inducing abilities to help them to “sleep off” the migraine in a quiet, dark room.
Triptans are a very effective treatment for migraine and can be used as an effective Abortive or Rescue medication in place of the medications suggested above. However due to their cost and the community prescribing rules in Australia, they are often used as a 2nd line medication here, where above options are ineffective.
Patients who suffer frequent recurrent migraines should be considered for a daily prophylactic treatment (eg pizotifen).
Emergency Department Management
The ED management of migraine is typically Rescue medication as the abortive window has long since passed by the time they arrive at the ED. The initial management in ED needs to take into account several factors and choice will depend on the clinician and department’s relative weighting of these
– medications already taken by the patient prior to ED presentation
– history of medications that have been effective at prior presentations
– contraindications/precautions/patient co-morbidities
– alternative differential diagnoses being considered at the time
– the ability to induce drowsiness: this may be useful to help the patient sleep off the migraine but may prolong their ED stay which may have implications for the department. It may also prevent the patient from driving home.
– risk v benefit of medication effectiveness v’s euphoria generation and likelihood of inducing drug seeking behaviour in a recurrently presenting condition
Medications that are frequently used in the ED rescue management of migraine include:
– potent NSAIDs eg high dose ibuprofen PO or ketoroloac IM
– IV chlorpromazine 12.5mg-25mg (often diluted in fluid as infusion)
– triptans: oral triptans are effective if patient is not vomiting but alternate routes including wafers, sub cut injection and intranasal are all available and effective in the vomiting patient. Examples include sumatriptan 50mg PO or 20mg intranasal.
– opioids: usually only considered in the patient refractory to treatments above due to their ability to induce drug seeking behaviour in the future and no evidence to suggest superior to above treatments.
While the chronic management of recurrent migraine is not typically in the domain of ED physicians, considering the patient’s need for appropriate Abortive, Rescue and (if needed) Prophylactic medications will help the patient over the longer term and should reduce their likelihood of presenting to ED. At the very least a discussion about these aspects of their management with the patient and referral to their GP to attend to this management should be provided by the ED clinician.
Due to the complex set of considerations discussed above taken into account when choosing an ED rescue treatment for migraine it is unlikely that one can only use or never use a particular treatment for migraine. The whole raft of options should remain in a clinician’s arsenal to use selectively as required, tailored to the individual patient.
IV Propofol may be a new weapon in this arsenal based on recent literature. Repeated low doses of propofol (eg 10-20mg) being delivered every 5-10 min seem to be able to significantly reduce migraine headache. The evidence is promising though larger RCT’s would be required to answer this question definitively. The major downside of this approach, despite the relative safety of these low doses, it that this would take a senior ED clinician off the floor to attend this patient’s bedside for extended periods (in the studies up to 30 minutes). However it may be a useful options for the small subset of patients who have been refractory to typical ED treatments above and perhaps it may even be considered before opioids in such patients as it is less likely to induce drug seeking behaviour.