Template:Non-specific headache treatment: Difference between revisions
(Convert headache medications to MedicationDose templates for SMW integration)
 
(11 intermediate revisions by 5 users not shown)
Line 1: Line 1:
===Non-specific [[Headache]]===
===Non-specific [[Headache]]===
''Treat specific headache type, if known''
''If known, treat specific headache type; avoid [[opioid]] medications if at all possible''
* 1st line: [[prochlorperazine]] (compazine) 10 mg IV (+/- [[diphenhydramine]] 25-50 mg IV) + 1 L normal saline IV bolus
* 1st line: {{MedicationDose|drug=Prochlorperazine|dose=10 mg IV|route=IV|context=1st line headache abortive|indication={{PAGENAME}}|population=Adult}} (+/- {{MedicationDose|drug=Diphenhydramine|dose=25-50 mg IV|route=IV|context=Adjunct to prevent akathisia|indication={{PAGENAME}}|population=Adult}}) + 1 L [[IVF]] bolus
**Place prochlorperazine in IV bag to reduce chances of side effects from rapid administration
**Place prochlorperazine in IV bag to reduce chances of side effects from rapid administration
**Alternative [[metoclopramide]] 10 mg IV<ref>Metoclopramide for Pain and Nausea in Patients with Migraine. Am Fam Physician. 2005 May 1;71(9):1770.</ref> ([[diphenhydramine]] addition shows no clinical benifit<ref>Friedman BW, et al. Diphenhydramine as Adjuvant Therapy for Acute Migraine: An Emergency Department-Based Randomized Clinical Trial. Annals of EM. January 2016. 67(1):32-39.</ref>)
**Alternative {{MedicationDose|drug=Metoclopramide|dose=10 mg IV|route=IV|context=Alternative abortive|indication={{PAGENAME}}|population=Adult}}<ref>Metoclopramide for Pain and Nausea in Patients with Migraine. Am Fam Physician. 2005 May 1;71(9):1770.</ref> ([[diphenhydramine]] addition shows no clinical difference in effectiveness<ref>Friedman BW, Irizarry E, Solorzano C, et al. Randomized study of IV prochlorperazine plus diphenhydramine vs IV prochlorperazine alone for migraine in the ED. Neurology 2017;89:1-6</ref>)
*[[Acetaminophen]] IV or PO, 325-1000 mg
*[[Acetaminophen]] IV or PO, 325-1000 mg
* [[Ketorolac]] 30 mg IV
* {{MedicationDose|drug=Ketorolac|dose=15-30 mg IV (30-60 mg IM)|route=IV/IM|context=NSAID for headache|indication={{PAGENAME}}|population=Adult}}
**Lower doses are shown to be just as effective<ref>Brown CR, Moodie JE, Wild VM, Bynum LJ. Comparison of intravenous ketorolac tromethamine and morphine sulfate in the treatment of postoperative pain. Pharmacotherapy. 1990;10(6Patient 2):116S-121S.</ref>
**Lower doses are shown to be just as effective<ref>Brown CR, Moodie JE, Wild VM, Bynum LJ. Comparison of intravenous ketorolac tromethamine and morphine sulfate in the treatment of postoperative pain. Pharmacotherapy. 1990;10(6Patient 2):116S-121S.</ref>
*[[Sumatriptan]] most effective within 6 hours of headache onset<ref>Efficacy and safety of intravenous acetylsalicylic acid lysinate compared to subcutaneous sumatriptan and parenteral placebo in the acute treatment of migraine. A double-blind, double-dummy, randomized, multicenter, parallel group study. The ASASUMAMIG Study Group. Diener HC. Cephalalgia. 1999 Jul; 19(6):581-8; discussion 542.</ref>
*{{MedicationDose|drug=Sumatriptan|dose=6 mg SC/IM (or 100 mg PO, or 1-2 sprays IN)|route=SC/IM/PO/IN|context=Triptan, most effective within 6h of onset|indication={{PAGENAME}}|population=Adult|notes=Max 12 mg SC/24h or 200 mg PO/24h}} <ref>Efficacy and safety of intravenous acetylsalicylic acid lysinate compared to subcutaneous sumatriptan and parenteral placebo in the acute treatment of migraine attacks. Cephalalgia. 1999;19(3):155-164.</ref>
**Serotonin 5HT1B/1D receptor agonist (e.g. [[sumatriptan]])
**Serotonin 5HT1B/1D receptor agonist (e.g. [[sumatriptan]])
**6 mg SQ or IM, may repeat dose x1 after 1 hour, max 12 mg / 24 hours
**6 mg SQ or IM, may repeat dose x1 after 1 hour, max 12 mg / 24 hours
**OR 100 mg PO, may repeat dose x1 after 2 hours, max 200 mg / 24 hours
**OR 100 mg PO, may repeat dose x1 after 2 hours, max 200 mg / 24 hours
**OR 1-2 sprays IN (may repeat after 2 hours)
**Contraindications to triptans include CV disease, uncontrolled [[HTN]], [[pregnancy]]
**Contraindications to triptans include CV disease, uncontrolled [[HTN]], [[pregnancy]]
*Consider [[dexamethasone]] 10 mg IV single dose to prevent recurrence 48-72 hrs post-ED discharge, if history of recurrent headaches<ref>Colman et al Paraenteral dexamethasone for acute severe migraine headache: meta-analysis of randomised controlled trials for preventing recurrence. BMJ 2008 Jun.;336(7657):1359–1361</ref>
*{{MedicationDose|drug=Dexamethasone|dose=4-10 mg IV x1|route=IV|context=Prevent headache recurrence 48-72h post-discharge|indication={{PAGENAME}}|population=Adult}}<ref>Colman et al Parenteral dexamethasone for acute severe migraine headache: meta-analysis of RCTs for preventing relapse. BMJ. 2008;336(7657):1359-61</ref>
*Avoid [[opioid]] medications if possible
** 10 mg IV single dose is commonly accepted regimen, 4 mg IV dose was shown to be as efficacious in a follow up study. <ref>Friedman BW, Solorzano C, Kessler BD, Martorello K, Lutz CL, Feliciano C, Adler N, Moss H, Cain D, Irizarry E. Randomized Trial Comparing Low- vs High-Dose IV Dexamethasone for Patients With Moderate to Severe Migraine. Neurology. 2023 Oct 3;101(14):e1448-e1454.</ref>
====Other 2nd and 3rd Line Medications====
 
*[[Magnesium]] 1 g IV over 30-60 minutes, low side effect profile, in treatment of acute migraine attacks<ref>Demirkaya S et al. Efficacy of intravenous magnesium sulfate in the treatment of acute migraine attacks. Headache. 2001 Feb;41(2):171-7.</ref>
====Other 2nd and 3rd Line Options====
*[[Valproate]] sodium 500-1000 mg IV in 50 mL of NS over 20 minutes (alternatively 10 mg/kg IV, pediatrics, max 500 mg)<ref>Shahien R et al. Intravenous sodium valproate aborts migraine headaches rapidly. Acta Neurol Scand. 2011 Apr;123(4):257-65.</ref>
*{{MedicationDose|drug=Magnesium sulfate|dose=1-2 g IV over 30-60 min|route=IV|context=2nd/3rd line for acute headache|indication={{PAGENAME}}|population=Adult}}<ref>Demirkaya S et al. Efficacy of intravenous magnesium sulfate in the treatment of acute migraine attacks. Headache, 41 (2001), pp. 171-177</ref>
*[[Droperidol]] IV/IM 1.25-2.75 mg, plus or minus diphenhydramine for extrapyramidal symptoms<ref>Thomas MC et al. Droperidol for the treatment of acute migraine headaches. Ann Pharmacother. 2015 Feb;49(2):233-40.</ref>
*{{MedicationDose|drug=Valproic acid|dose=500-1000 mg IV in 50 mL NS over 20 min (peds: 10 mg/kg, max 500 mg)|route=IV|context=2nd/3rd line for acute headache|indication={{PAGENAME}}|population=Adult|display=Valproate sodium}}<ref>Shahien R et al. Intravenous sodium valproate aborts migraine headaches rapidly. Acta Neurol Scand. 2011 Apr;123(4):257-65.</ref>
*{{MedicationDose|drug=Droperidol|dose=1.25-2.75 mg IV or IM|route=IV/IM|context=2nd/3rd line for acute headache|indication={{PAGENAME}}|population=Adult|notes=Monitor EKG for QTc prolongation}}<ref>Thomas MC et al. Droperidol for the treatment of acute migraine headaches. Ann Pharmacother. 2015 Feb;49(2):233-40.</ref>
**Perform EKG monitoring for patients at risk of QTc prolongation
**Perform EKG monitoring for patients at risk of QTc prolongation
**Do not give to patients who take already multiple QT prolonging drugs
**Do not give to patients who take already multiple QT prolonging drugs
*Consider [[haloperidol]] IV 5 mg in IVF bolus with [[diphenhydramine]] to prevent need for rescue medications<ref>Gaffigan ME et al. A Randomized Controlled Trial of Intravenous Haloperidol vs. Intravenous Metoclopramide for Acute Migraine Therapy in the Emergency Department. J Emerg Med. 2015 Sep;49(3):326-34.</ref>
*Consider [[haloperidol]] IV 5 mg in IVF bolus with [[diphenhydramine]] to prevent need for rescue medications<ref>Gaffigan ME et al. A Randomized Controlled Trial of Intravenous Haloperidol vs. Intravenous Metoclopramide for Acute Migraine Therapy in the Emergency Department. J Emerg Med. 2015 Sep;49(3):326-34.</ref>
*Consider 5-10 mg PO [[olanzapine]] (Zyprexa, Zydis) for prochlorperazine allergy<ref>Silberstein SD et al. Olanzapine in the treatment of refractory migraine and chronic daily headache. Headache. 2002 Jun;42(6):515-8.</ref><ref>Rozen TD. Olanzapine as an abortive agent for cluster headache. Headache. 2001;41(8):813-816.</ref>
*Consider 5-10 mg PO [[olanzapine]] (Zyprexa, Zydis) for prochlorperazine allergy<ref>Silberstein SD et al. Olanzapine in the treatment of refractory migraine and chronic daily headache. Headache. 2002 Jun;42(6):515-8.</ref><ref>Rozen TD. Olanzapine as an abortive agent for cluster headache. Headache. 2001;41(8):813-816.</ref>
**While less extrapyramidal symptoms than typical antipsychotics, beware [[QT prolongation]]
**Particularly useful in psych patients with mania, BPD, psychosis
**Particularly useful in psych patients with mania, BPD, psychosis
**IV olanzapine may be as safe or safer than IM, with faster onset<ref>Farkas J. PulmCrit. PulmCrit- Intravenous olanzapine: Faster than IM olanzapine, safer than IV haloperidol? Feb 1, 2016. http://emcrit.org/pulmcrit/intravenous-olanzapine-haloperidol/</ref>
**IV olanzapine may be as safe or safer than IM, with faster onset<ref>Farkas J. PulmCrit. PulmCrit- Intravenous olanzapine: Faster than IM olanzapine, safer than IV haloperidol? Feb 1, 2016. http://emcrit.org/pulmcrit/intravenous-olanzapine-haloperidol/</ref>
Line 30: Line 31:
**Great for patients without an IV
**Great for patients without an IV
**10 cm cotton-tipped applicator soaked in lidocaine or bupivicaine and inserted nasally along the superior border of the middle turbinate and left for 5-10 minutes <ref>https://www.aliem.com/2017/03/trick-sphenopalatine-ganglion-block-primary-headaches/</ref>
**10 cm cotton-tipped applicator soaked in lidocaine or bupivicaine and inserted nasally along the superior border of the middle turbinate and left for 5-10 minutes <ref>https://www.aliem.com/2017/03/trick-sphenopalatine-ganglion-block-primary-headaches/</ref>
*Greater occipital nerve block
*Consider [[greater occipital nerve block]]
**For refractory occipital migraine, cluster headache, occipital neuralgia, cervicogenic headache, or migraine with occipital nerve irritation or tenderness <ref>https://www.nuemblog.com/blog/occipital-nerve-block</ref>
**For refractory occipital migraine, cluster headache, occipital neuralgia, cervicogenic headache, or migraine with occipital nerve irritation or tenderness <ref>https://www.nuemblog.com/blog/occipital-nerve-block</ref>
**Typically, a local anesthetic such as lidocaine (1-2%) or bupivacaine (0.5%) (or a combination of the two) is injected.  Lidocaine has a quicker onset, while bupivacaine has a longer lasting effect.  Total volume injected is 2-4cc per nerve block.
**Identify the location of the greater occipital nerve via one of 3 methods:
**Palpate the occipital artery pulse about 2cm lateral to the occipital protuberance.  The greater occipital nerve is just medial to the occipital artery
**Alternatively, palpate the occipital protuberance and the mastoid process (on side of interest). Measure 1/3 the distance between the two points starting from the occipital protuberance. Stay just superior to the superior nuchal line to remain over the cranium.
**Alternatively, identify the point of maximal tenderness in the general region as defined above that may elicit paresthesia in the occipital nerve distribution when palpated
**Clean the site of injection. Using a 23-25G needle, insert the needle at a 90-degree angle toward the occiput until a bony endpoint is obtained.  Aspirate to avoid intravascular injection and to prevent injection into CSF.  Inject 1cc at the GON, 1cc medial to the nerve, and 1cc lateral to the nerve. 
*Severe, intractable status migrainosus may benefit from off-label IV [[propofol]]<ref>The Efficacy of Propofol vs. Subcutaneous Sumatriptan for Treatment of Acute Migraine Headaches in the Emergency Department: A DBCT. Pain Prac. 2014 Jul 12.</ref><ref>Fortuitous Finding – IV Propofol: Unique Effectiveness in Treating Intractable Migraine.  Krusz, John C.  Headache 2000;40:224-230.</ref><ref>Simmonds MK. The effect of single-dose porpofol injection on pain and quality of life in chronic daily headaches: a RDBCT. Anesth Analg. 2009 3Dec;109(6):1972-80.</ref>
*Severe, intractable status migrainosus may benefit from off-label IV [[propofol]]<ref>The Efficacy of Propofol vs. Subcutaneous Sumatriptan for Treatment of Acute Migraine Headaches in the Emergency Department: A DBCT. Pain Prac. 2014 Jul 12.</ref><ref>Fortuitous Finding – IV Propofol: Unique Effectiveness in Treating Intractable Migraine.  Krusz, John C.  Headache 2000;40:224-230.</ref><ref>Simmonds MK. The effect of single-dose porpofol injection on pain and quality of life in chronic daily headaches: a RDBCT. Anesth Analg. 2009 3Dec;109(6):1972-80.</ref>
**Requires procedural sedation monitoring and possible IV fluid resuscitation, respiratory decompensation intervention
**Requires procedural sedation monitoring and possible IV fluid resuscitation, respiratory decompensation intervention

Latest revision as of 22:34, 20 March 2026

Non-specific Headache

If known, treat specific headache type; avoid opioid medications if at all possible

  • 1st line: Prochlorperazine 10 mg IV IV (+/- Diphenhydramine 25-50 mg IV IV) + 1 L IVF bolus
    • Place prochlorperazine in IV bag to reduce chances of side effects from rapid administration
    • Alternative Metoclopramide 10 mg IV IV[1] (diphenhydramine addition shows no clinical difference in effectiveness[2])
  • Acetaminophen IV or PO, 325-1000 mg
  • Ketorolac 15-30 mg IV (30-60 mg IM) IV/IM
    • Lower doses are shown to be just as effective[3]
  • Sumatriptan 6 mg SC/IM (or 100 mg PO, or 1-2 sprays IN) SC/IM/PO/IN — Max 12 mg SC/24h or 200 mg PO/24h [4]
    • Serotonin 5HT1B/1D receptor agonist (e.g. sumatriptan)
    • 6 mg SQ or IM, may repeat dose x1 after 1 hour, max 12 mg / 24 hours
    • OR 100 mg PO, may repeat dose x1 after 2 hours, max 200 mg / 24 hours
    • OR 1-2 sprays IN (may repeat after 2 hours)
    • Contraindications to triptans include CV disease, uncontrolled HTN, pregnancy
  • Dexamethasone 4-10 mg IV x1 IV[5]
    • 10 mg IV single dose is commonly accepted regimen, 4 mg IV dose was shown to be as efficacious in a follow up study. [6]

Other 2nd and 3rd Line Options

  • Magnesium sulfate 1-2 g IV over 30-60 min IV[7]
  • Valproate sodium 500-1000 mg IV in 50 mL NS over 20 min (peds: 10 mg/kg, max 500 mg) IV[8]
  • Droperidol 1.25-2.75 mg IV or IM IV/IM — Monitor EKG for QTc prolongation[9]
    • Perform EKG monitoring for patients at risk of QTc prolongation
    • Do not give to patients who take already multiple QT prolonging drugs
  • Consider haloperidol IV 5 mg in IVF bolus with diphenhydramine to prevent need for rescue medications[10]
  • Consider 5-10 mg PO olanzapine (Zyprexa, Zydis) for prochlorperazine allergy[11][12]
    • Particularly useful in psych patients with mania, BPD, psychosis
    • IV olanzapine may be as safe or safer than IM, with faster onset[13]
  • Ketamine IM/IV at subdissociative dosages, with risk stratification for potential ICP increase, though now widely considered a myth[14]
  • Cervical spine injection with IM injection of 1.5 mL of 0.5% bupivacaine (plus or minus methylprednisolone acetate) bilaterally to the sixth or seventh spinous process[15]
  • Sphenopalatine ganglion block
    • Great for patients without an IV
    • 10 cm cotton-tipped applicator soaked in lidocaine or bupivicaine and inserted nasally along the superior border of the middle turbinate and left for 5-10 minutes [16]
  • Consider greater occipital nerve block
    • For refractory occipital migraine, cluster headache, occipital neuralgia, cervicogenic headache, or migraine with occipital nerve irritation or tenderness [17]
  • Severe, intractable status migrainosus may benefit from off-label IV propofol[18][19][20]
    • Requires procedural sedation monitoring and possible IV fluid resuscitation, respiratory decompensation intervention
    • Propofol 0.5 mg/kg bolus, then 0.25 mg/kg every 10 minutes for 1 hour
    • Less aggressive regimens include propofol 10 mg q5-10 min to ma of 80 mg[21]
    • Consider using 1 mL 2% lidocaine added to every 10 mL of 10 mg/mL concentration propofol
    • Average dosage required ~100-125 mg
  1. ↑ Metoclopramide for Pain and Nausea in Patients with Migraine. Am Fam Physician. 2005 May 1;71(9):1770.
  2. ↑ Friedman BW, Irizarry E, Solorzano C, et al. Randomized study of IV prochlorperazine plus diphenhydramine vs IV prochlorperazine alone for migraine in the ED. Neurology 2017;89:1-6
  3. ↑ Brown CR, Moodie JE, Wild VM, Bynum LJ. Comparison of intravenous ketorolac tromethamine and morphine sulfate in the treatment of postoperative pain. Pharmacotherapy. 1990;10(6Patient 2):116S-121S.
  4. ↑ Efficacy and safety of intravenous acetylsalicylic acid lysinate compared to subcutaneous sumatriptan and parenteral placebo in the acute treatment of migraine attacks. Cephalalgia. 1999;19(3):155-164.
  5. ↑ Colman et al Parenteral dexamethasone for acute severe migraine headache: meta-analysis of RCTs for preventing relapse. BMJ. 2008;336(7657):1359-61
  6. ↑ Friedman BW, Solorzano C, Kessler BD, Martorello K, Lutz CL, Feliciano C, Adler N, Moss H, Cain D, Irizarry E. Randomized Trial Comparing Low- vs High-Dose IV Dexamethasone for Patients With Moderate to Severe Migraine. Neurology. 2023 Oct 3;101(14):e1448-e1454.
  7. ↑ Demirkaya S et al. Efficacy of intravenous magnesium sulfate in the treatment of acute migraine attacks. Headache, 41 (2001), pp. 171-177
  8. ↑ Shahien R et al. Intravenous sodium valproate aborts migraine headaches rapidly. Acta Neurol Scand. 2011 Apr;123(4):257-65.
  9. ↑ Thomas MC et al. Droperidol for the treatment of acute migraine headaches. Ann Pharmacother. 2015 Feb;49(2):233-40.
  10. ↑ Gaffigan ME et al. A Randomized Controlled Trial of Intravenous Haloperidol vs. Intravenous Metoclopramide for Acute Migraine Therapy in the Emergency Department. J Emerg Med. 2015 Sep;49(3):326-34.
  11. ↑ Silberstein SD et al. Olanzapine in the treatment of refractory migraine and chronic daily headache. Headache. 2002 Jun;42(6):515-8.
  12. ↑ Rozen TD. Olanzapine as an abortive agent for cluster headache. Headache. 2001;41(8):813-816.
  13. ↑ Farkas J. PulmCrit. PulmCrit- Intravenous olanzapine: Faster than IM olanzapine, safer than IV haloperidol? Feb 1, 2016. http://emcrit.org/pulmcrit/intravenous-olanzapine-haloperidol/
  14. ↑ Sin B et al. The use of subdissociative-dose ketamine for acute pain in the emergency department. Acad Emerg Med. 2015 Mar;22(3):251-7.
  15. ↑ Mellick LB et al. Treatment of headaches in the ED with lower cervical intramuscular bupivacaine injections: a 1-year retrospective review of 417 patients. Headache. 2006 Oct;46(9):1441-9.
  16. ↑ https://www.aliem.com/2017/03/trick-sphenopalatine-ganglion-block-primary-headaches/
  17. ↑ https://www.nuemblog.com/blog/occipital-nerve-block
  18. ↑ The Efficacy of Propofol vs. Subcutaneous Sumatriptan for Treatment of Acute Migraine Headaches in the Emergency Department: A DBCT. Pain Prac. 2014 Jul 12.
  19. ↑ Fortuitous Finding – IV Propofol: Unique Effectiveness in Treating Intractable Migraine. Krusz, John C. Headache 2000;40:224-230.
  20. ↑ Simmonds MK. The effect of single-dose porpofol injection on pain and quality of life in chronic daily headaches: a RDBCT. Anesth Analg. 2009 3Dec;109(6):1972-80.
  21. ↑ Soleimanpour et al. BMC Neurology 2012. 12:114. 90 pts in ED w/ Migraine.
Retrieved from "https://www.wikem.org/w/index.php?title=Template:Non-specific_headache_treatment&oldid=387561"