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.
- 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