Symptom Finder - Treatment of Migraine
8)HEADACHE, MIGRAINE
Acute attack:
1. Sumatriptan (Imitrex): 25–50 mg p.o. or 6 mg SC may repeat oral or SC dose once more in 24 hours.
2. Alternatively may use other 5-HT receptor agonists
3. Oxygen: 6 L/min preferably by mask; also useful during the acute attack.
4. Metoclopramide (Reglan): 5–10 mg IM q6hrs PRN is preferred for nausea and vomiting but may use a phenothiazine.
5. Dexamethasone (Decadron): 8–12 mg IM or IV may abort an attack especially in status migrainosus.
6. Diphenhydramine (Benadryl): 75–150 mg IV (slowly) has also been successful in aborting an attack.
7. Standard analgesics such as morphine sulfate 10–15 mg IM or IV and meperidine
(Demerol) 50–75 mg IM may be necessary but should be avoided if possible.
Prophylaxis:
1. Cyproheptadine (Periactin): 4–8 mg tid. This is especially useful in children.
2. Metoprolol (Lopressor): 25–50 mg bid. Monitor pulse and do not give if below 50/min.
3. Other β-blockers may be tried
4. Valproate (Depakote): 250–1,000 mg bid according to blood level.
5. Other anticonvulsants may be tried
6. Verapamil SR (Calan): 120–240 mg bid as long acting preparation.
7. Amitriptyline (Elavil): 50–150 mg h.s.
8. Fluoxetine (Prozac): 10–80 mg daily.
9. Other SSRIs may be tried
10. Tyramine-free diet: especially avoid chocolate, nuts, and cheeses. However, citrus fruits, meats cured with nitrates, and caffeinated beverages are not uncommon causes of migraine.
11. Naproxen (Naprosyn): 500 mg bid–tid. Other NSAIDs may be tried
12. Difficult cases should be referred to a neurologist.
Acute attack:
1. Sumatriptan (Imitrex): 25–50 mg p.o. or 6 mg SC may repeat oral or SC dose once more in 24 hours.
2. Alternatively may use other 5-HT receptor agonists
3. Oxygen: 6 L/min preferably by mask; also useful during the acute attack.
4. Metoclopramide (Reglan): 5–10 mg IM q6hrs PRN is preferred for nausea and vomiting but may use a phenothiazine.
5. Dexamethasone (Decadron): 8–12 mg IM or IV may abort an attack especially in status migrainosus.
6. Diphenhydramine (Benadryl): 75–150 mg IV (slowly) has also been successful in aborting an attack.
7. Standard analgesics such as morphine sulfate 10–15 mg IM or IV and meperidine
(Demerol) 50–75 mg IM may be necessary but should be avoided if possible.
Prophylaxis:
1. Cyproheptadine (Periactin): 4–8 mg tid. This is especially useful in children.
2. Metoprolol (Lopressor): 25–50 mg bid. Monitor pulse and do not give if below 50/min.
3. Other β-blockers may be tried
4. Valproate (Depakote): 250–1,000 mg bid according to blood level.
5. Other anticonvulsants may be tried
6. Verapamil SR (Calan): 120–240 mg bid as long acting preparation.
7. Amitriptyline (Elavil): 50–150 mg h.s.
8. Fluoxetine (Prozac): 10–80 mg daily.
9. Other SSRIs may be tried
10. Tyramine-free diet: especially avoid chocolate, nuts, and cheeses. However, citrus fruits, meats cured with nitrates, and caffeinated beverages are not uncommon causes of migraine.
11. Naproxen (Naprosyn): 500 mg bid–tid. Other NSAIDs may be tried
12. Difficult cases should be referred to a neurologist.