Migraine in the Emergency Room

We are currently writing new SOPs for some of the standard neurological emergency room problems – one of them being classical migraine. So don’t worry about the differential, sinus vein thrombosis etc. but assume a classical migraine presentation – how do you treat this? Luckily, there is a good reference for this situation in a 3-part series in Headache 2012 (available on our local neuro drive). Here is my personal view on this:

  • Start with Novalgin (Metamizol) 1g + Vomex (Dimenhydrinat which is roughly Diphenhydramin) iv
  • After 20 min add Mg 1 ampule

Next choose among the following options:

  • Promethazin 50 mg or Haloperidol 5 mg (ECG!) iv
  • Valproate 300-300 mg iv
  • Dexamethasone 10 mg iv
  • Propofol 30-20-20-20-20 mg iv until pt is sleeping (my favorite, ambu bag!, monitor)
  • Sumatriptan 6 mg sc or 10 mg intranasally.

Remarks:

  • Quite surprisingly, triptans don’t work very well in the ER unless parenterally – which is quite expensive. Don’t give up on it, though, if you are lucky to have the 40€ one hit costs.
  • I don’t like opiates for migraine – it might lead to hypersensitivity.
  • I don’t like Paracetamol ~ Acetaminophen, because there are no iv studies for it.
  • I like ASS 1g iv but again there is no proper iv study for it.
  • Dihydroergotamin is not available for iv in Germany
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