HA- Treatment Considerations

Question 1

Acute migraine pharmacotherapy tips

Answer 1

Abortive treatments are usually more effective in the early stages of the HA

A large, single dose is better than repetitive, small doses

Counsel on medication overuse HA

Question 2

Treatments for severe migraine in the ED

Answer 2

IV/IM dexamethasone
SQ sumatriptan
IV prochlorperazine and diphenhydramine
IV metoclopramide and diphenhydramine
IV chlorpromazine and diphenhydramine
IV DHE and antiemetic (like metoclopramide)
IV VPA
IV/IM ketorolac
IV magnesium

Question 3

Caveat about IV/IM dexamethasone for severe migraine treatment

Answer 3

It doesn’t do anything for immediate HA relief, but when added to standard acute migraine treatment, it decreases the rate of early HA recurrence

Question 4

Medication used in severe migraine treatment with a quick onset of action

Answer 4

SQ sumatriptan

Question 5

What is diphenhydramine’s role in IV formulations with prochlorperazine, metoclopramide, and chlorpromazine?

Answer 5

Reduce akathisia and dystonic reactions

Question 6

Opioids and barbiturates in migraine treatment

Answer 6

Basically: DON’T USE THEM! Use them as a backup plan for patients who don’t respond to other treatments or have CIs to other treatments because overuse can lead to medication overuse headache

Question 7

When to consider migraine preventative treatment

Answer 7

Attacks significantly interfere with daily routines despite acute treatment
Frequent attacks
CI to, failure, or overuse of acute treatments
ADEs with acute treatments
Patient preference

Question 8

Medications used for migraine preventative treatment

Answer 8

Topiramate, VPA, beta-blockers, SNRIs, CGRP monoclonal antibodies (as a last-resort), peripheral nerve blocks

Question 9

Meds used in a greater occipiital nerve block

Answer 9

IM injection of lidocaine and/or bupivacaine and/or methylprednisone

Question 10

ADEs of peripheral nerve blocks

Answer 10

Lightheaded and dizziness that goes away after a few hours

Question 11

Contraceptives in migraine

Answer 11

Estrogen increases the risk of ischemic stroke and should be avoided by women with migraine with aura who already have an increased stroke risk

Question 12

Acute migraine treatment for patients with cardiovascular/cerebrovascular disease

Answer 12

gepants and lasmiditan

Question 13

Acute migraine treatment for pregnant patients

Answer 13

APAP IS FIRST LINE, AVOID NSAIDs IN THE 3RD TRIMESTER!

Question 14

Nonpharm treatments for migraines

Answer 14

Stress reduction techniques, dietary changes, trigger avoidance, Mg, Vitamin B2, feverfew, butterbur, neuromodulation devices