Migraine: Management

00:01 So what should we do to treat these patients? Definitely when people come to the Emergency Department, one of our goals is to try and get them feeling better.

00:09 Our primary goal is to rule out any bad or very serious, or dangerous cause of their headache.

00:14 And then the next step is to get people feeling better.

00:17 So patients who have a more mild headache, you can give a non-steroidal anti-inflammatory medication.

00:22 The most common ones there are ibuprofen as well as mainly ibuprofen or Ketorolac is the other one.

00:31 Acetaminophen is the other medication that can sometimes be given.

00:35 For patients who have a more moderate to severe headache, and that's generally what we're seeing in the Emergency Department, it would be unusual for someone to come in with a headache that they described as being a little bit more mild.

00:48 So for the more moderate to severe headaches, we wanna think about giving a dopamine antagonist, or an antiemetic medication.

00:54 And the classic ones that we give are metoclopramide or prochlorperazine.

00:58 And those are generally given intravenously in order for them to be the most effective.

01:05 We also wanna consider giving some kind of dihydroergotamine or sumatriptan, parenteral steroids, so IV steroid can sometimes also benefit especially if the initial medications don't necessarily work.

01:19 Newer 2nd-line medication options include CGRP antagonists, such as rimegepant or ubrogepant, and lasmiditan, which is a selective serotonin 1F receptor agonist.

01:33 Intravenous fluids may be used, but newer evidence supports that fluids may not significantly improve patients symptoms.

01:41 Depakote or Valproic acid may be used for patients who are having a refractory headache.

01:48 So those are generally the medications that we start with.

01:52 There’s definitely other things that can be given as well.

01:55 But those are the most common treatment pathways that we use for patients with migraine headache in the Emergency Department.

02:01 One thing that’s important for you to remember to avoid are opioid medications.

02:05 And the reason that we avoid opioid medications are multi.

02:09 But for the most part, they can lead to a rebound headaches.

02:12 So if you give someone an opioid medication or they’re chronically an opioid medications for migraine headaches, once that medication wears off, the patient can get a rebound headache or potentially a more severe headache.

02:24 There are also issues associated with opioid medications being addictive for patients.

02:29 So for the most part in the Emergency department, that’s a medication that you wanna try and avoid giving for patients who presents with headaches.