Template:Non-specific headache treatment

Non-specific Headache

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 IVF bolus
    • Place prochlorperazine in IV bag to reduce chances of side effects from rapid administration
    • Alternative metoclopramide 10 mg IV[1] (diphenhydramine addition shows no clinical benifit[2])
  • Acetaminophen IV or PO, 325-1000 mg
  • Ketorolac 10-30 mg IV (30-60mg IM)
    • Lower doses are shown to be just as effective[3]
  • Sumatriptan most effective within 6 hours of headache onset[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
  • Consider dexamethasone 10 mg IV single dose to prevent recurrence 48-72 hrs post-ED discharge, if history of recurrent headaches[5]

Other 2nd and 3rd Line Options

  • Magnesium 1-2 g IV over 30-60 minutes, low side effect profile, in treatment of acute migraine attacks[6]
  • Valproate sodium 500-1000 mg IV in 50 mL of NS over 20 minutes (alternatively 10 mg/kg IV, pediatrics, max 500 mg)[7]
  • Droperidol IV/IM 1.25-2.75 mg, plus or minus diphenhydramine for extrapyramidal symptoms[8]
    • 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[9]
  • Consider 5-10 mg PO olanzapine (Zyprexa, Zydis) for prochlorperazine allergy[10][11]
    • Particularly useful in psych patients with mania, BPD, psychosis
    • IV olanzapine may be as safe or safer than IM, with faster onset[12]
  • Ketamine IM/IV at subdissociative dosages, with risk stratification for potential ICP increase, though now widely considered a myth[13]
  • 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[14]
  • 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 [15]
  • Consider greater occipital nerve block
    • For refractory occipital migraine, cluster headache, occipital neuralgia, cervicogenic headache, or migraine with occipital nerve irritation or tenderness [16]
  • Severe, intractable status migrainosus may benefit from off-label IV propofol[17][18][19]
    • 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[20]
    • 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, 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.
  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. 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.
  5. 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
  6. Demirkaya S et al. Efficacy of intravenous magnesium sulfate in the treatment of acute migraine attacks. Headache. 2001 Feb;41(2):171-7.
  7. Shahien R et al. Intravenous sodium valproate aborts migraine headaches rapidly. Acta Neurol Scand. 2011 Apr;123(4):257-65.
  8. Thomas MC et al. Droperidol for the treatment of acute migraine headaches. Ann Pharmacother. 2015 Feb;49(2):233-40.
  9. 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.
  10. Silberstein SD et al. Olanzapine in the treatment of refractory migraine and chronic daily headache. Headache. 2002 Jun;42(6):515-8.
  11. Rozen TD. Olanzapine as an abortive agent for cluster headache. Headache. 2001;41(8):813-816.
  12. Farkas J. PulmCrit. PulmCrit- Intravenous olanzapine: Faster than IM olanzapine, safer than IV haloperidol? Feb 1, 2016. http://emcrit.org/pulmcrit/intravenous-olanzapine-haloperidol/
  13. 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.
  14. 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.
  15. https://www.aliem.com/2017/03/trick-sphenopalatine-ganglion-block-primary-headaches/
  16. https://www.nuemblog.com/blog/occipital-nerve-block
  17. The Efficacy of Propofol vs. Subcutaneous Sumatriptan for Treatment of Acute Migraine Headaches in the Emergency Department: A DBCT. Pain Prac. 2014 Jul 12.
  18. Fortuitous Finding – IV Propofol: Unique Effectiveness in Treating Intractable Migraine. Krusz, John C. Headache 2000;40:224-230.
  19. 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.
  20. Soleimanpour et al. BMC Neurology 2012. 12:114. 90 pts in ED w/ Migraine.