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  • Migraine Treatment
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First line abortive therapies for ER patients

  • Hydration
  • Valproate (Depacon) 5-10 mg/kg IV rate <20 mg/min
  • IV Anti-emetics
    • Prochlorperazine (Compazine)
    • Metoclopramide (Reglan)
    • Promethazine (Phenergan)
  • Steroids
    • Methylprednisolone (Solumedrol) 1 gram IV once
    • Prednisone taper

First Line Abortive Therapies For Outpatients

  • NSAIDs
  • Acetaminophen/isometheptene/dichloralphenazone (Midrin)
  • Triptans
    • Don't use in patients with cardiac disorders.
    • Generally, avoid if the patient has focal neurological deficits with their headaches.
    • Triptans are most effective if taken at headache onset
      • Sumatriptan (Imitrex): 25 mg / 50 mg / 100 mg tabs. Can start with a 6 mg SC stat dose. Nasal as well. Max 200 mg/24 hours
      • Zolmatriptan (Zomig): 1/2.5/5 mg. Dissolves on tongue. Max 10 mg/24 hours
      • Rizatriptan (Maxalt): 5 mg / 10 mg. Also comes as a dissolveable wafer (Maxalt-MLT)
      • Naratriptan (Amerge) 1 mg / 2.5 mg

Other Abortive Agents

  • DHE 45
    • Used as abortive in status migranosis.
    • Contraindicated in PVD, CAD, HTN, pregnancy, nursing, some others.
    • Usually give Prochlorperazine (Compazine) before as it can cause severe nausea.
    • DHE 45 can be given IV/IM/SC/Nasal.
    • DHE Protocol
  • Chlorpromazine (Thorazine) 25-50 mg IM or 7.5 mg IV. Watch BP.
  • Aspirin
  • Acetaminophen/Aspirin/Caffeine (Excedrin, Excedrin Migraine)
  • Caffeine/Ergotamine (Cafergot)
  • Ketorolac (Toradol)
  • Oxygen
    • Try 100% (i.e. >12-15 LPM)
    • Give via non-rebreather.
  • Narcotics SPARINGLY!.

Prophylactic Treatment

  • Start low, and titrate up slowly
  • Give each drug an adequate trial!
  • Warn patients that relief is not instant – may take weeks to notice any improvement.
  • Get rid of other precipitants (chronic NSAID use/rebound, narcs, poor sleep habits, OSA, caffeine, etc)
  • Tricyclics
    • Consider EKG with initiation to assess QT interval.
    • Dangerous in overdose, so be careful in depressed patients.
      • Nortriptyline (Pamelor): Start 25 qHS, titrate up by 25 every week or two. Max 150.
      • Amitriptyline (Elavil): Start 10-25 mg qHS, and titrate up by 25 mg every week or two.
  • Beta-Blockers
    • Risk of hypotension
    • Can worsen asthma
      • Propranolol (Inderal): start 40-60 mg daily
      • Timolol
      • Nadolol
  • Calcium Channel Blockers
    • Verapamil (Calan)
      • Can increase to 720 mg in cluster headaches
  • Anti-epileptics
    • Topiramate (Topamax): Start 25 mg qHS, increase by 25 mg/week to 50 BID or higher if necessary.
      • Can cause weight loss.
      • Caution in patients with a history of kidney stones.
    • Valproic acid (Depakote/Depakote ER)
      • Can cause weight gain.
    • Anti-Histamines
      • Cyproheptadine (Periactin)
    • Ergotamines
      • Usually a last resort
      • Methergine: 0.2 mg daily, increase by one dose per week until at 0.2 mg TID.
    • We do NOT usually use narcotics for chronic headaches.
  •  Vitamins
    • Riboflavin - NEUROLOGY 1998;50:466-470
    • Magnesium
    • CoQ10 - NEUROLOGY 2005;64:713-715

Abortive migraine medications

Acetaminophen (Tylenol)
Ibuprofen (Advil)
Naproxen (Aleve)
Indomethacine (Indocin)
Ketorolac (Toradol)
Acetylsalicylic acid (Aspirin, Ecotrin)
Acetaminophen/Isometheptene/Dichloralphenazone (Midrin)
Almotriptan (Axert)
Frovatriptan (Frova)
Zolmitriptan (Zomig)
Eletriptan (Relpax)
Naratriptan (Amerge)
Sumatriptan (Imitrex)
Sumatriptan/Naproxen (Treximet)
Rizatriptan (Maxalt)
Isometheptene/Dichloralpherazone/Acetaminophen (Midrin)
Prochlorperazine (Compazine)
Promethazine (Phenergan)
Chlorpromazine (Thorazine)
Perphenazine (Triavil, Trilafon)
Metoclopramide (Reglan)
Acetaminophen/Aspirin/Caffeine (Excedrin, Excedrin Migraine)
Acetaminophen/Butalbital/Caffeine (Fioracet)
Aspirin/Butalbital/Caffeine (Fiorinal)
Dihydroergotamine (DHE 45)
Caffeine/Ergotamine (Cafergot)
Prednisone (Deltasone, Prednicot, Sterapred)
Methylprednisolone (Solu-Medrol)
Dexamethasone (Decadron)

Prophylactic migraine medications

Amitriptyline (Elavil)
Doxepin (Sinequan)
Imipramine (Tofranil)
Nortriptyline (Pamelor)
Methysergide (Sansert)
Methylergonovine (Methergine)
Atenolol (Tenormin)
Propranolol (Inderal)
Metoprolol (Toprol)
Nadolol (Corgard)
Timolol (Blocadren)
Verapamil (Calan)
Nimodipine (Nimotop)
Nifedipine (Procardia)
Losartan (Cozaar)
Baclofen (Lioresal)
Topiramate (Topamax)
Carbamazepine (Tegretol)
Divalproex (Depakote)
Levetiracetam (Keppra)
Lamotrigine (Lamictal)
Gabapentin (Neurontin)
Cyproheptadine (Periactin)
Duloxetine (Cymbalta)
Fluoxetine (Prozac)
Acetazolamide (Diamox)
Quetiapine (Seroquel)
Trazodone (Desyrel)
Lithium (Eskolith)
Acetylsalicylic acid (Aspirin, Ecotrin)
Coenzyme Q10
Riboflavin (Vitamin B2)
Vitamin B12

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