What Will the ER Give Me for My Migraine?

Migraine Medications in the Emergency Room

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What Medication Will They Give Me in the Emergency Room for My Migraine?. slobo/Vetta/Getty Images

Sometimes, the pain of a migraine attack is so intense that it requires an emergency room visit. Or, in other cases, the nausea and/or vomiting that accompany a migraine attack limits oral medication intake. In emergency rooms or urgent care centers, acute migraine attacks are often treated with intravenous medications. But, which one is best?

One double-blind study in Neurology randomized 330 patients with an acute migraine attack to receive either 1g valproate, 10mg metoclopramide, or 30mg ketorolac.

Valproate is an anti-convulsant medication that in its oral form is sometimes used to prevent migraines. In fact, the American Academy of Neurology concluded that the valproate products, divalproex sodium and sodium valproate, are effective (Level A drugs) in preventing migraines. Side effects of valproate medications include: weight gain, nausea, tremor, and hair loss.

Metoclopramide (Reglan) is an anti-emetic or anti-nausea medication. It blocks dopamine receptors in the brain and primarily alleviates gastric stasis. It is commonly used as a single agent for aborting migraines in emergency rooms. It can cause a feeling of restlessness.

Ketorolac is an NSAID with a rapid onset of action. Like Reglan, it is commonly used in emergency rooms to abort migraines. In one study, it was found to be more effective than intranasal sumatriptan in alleviating acute migraines. Remember, though, NSAIDs do have several potential adverse effects and should be avoided by some individuals, particularly those with a history of stomach bleeding, kidney disease, and/or heart disease.

What Does the Study Show?

In the study, all of the patients reported an initial score of ≥ 7 on a 0 to 10 pain scale, and the majority were not taking a preventive migraine therapy. After one hour of receiving the medication, those who received valproate improved by a score average of 2.8 whereas those who received metoclopramide and ketorolac improved by an average of 4.7 and 3.9 points, respectively.

The recipients of valproate required more rescue medications (69%) compared with those who received metoclopramide (33%) and ketorolac (52%). Finally, a greater number of recipients of metoclopramide preferred to receive this same medication at a future emergency room visit compared with the other two groups (61% vs 26% for valproate and 40% for ketorolac).

Finally, at 24 hours after initial medication administration, sustained headache relief was low in all three groups: valproate (4%), metoclopramide (11%), and ketorolace (16%). This is not a great conclusion, as we want patients to feel long-lasting relief from their head pain.

What Does This All Mean?

  • Metoclopramide and ketorolac may be preferred over valproate as an IV medication for migraine attacks in the emergency room.
  • Metoclopramide appears to be the preferred medication among patients who go to the ER for a migraine.
  • The majority of the subjects did not have sustained relief of their head pain. Basically, we need more efficacious therapy to provide pain relief for migraineurs during an acute, severe attack.
  • Please note that the majority of the subjects were not taking a migraine preventive therapy. This makes it difficult to generalize the results to those with more severe and/or chronic migraine.

Take Home Message

If you end up going to the ER for an acute migraine attack, you very well may receive an IV dose of metoclopramide, ketorolac, or valproate. If you have a choice, metoclopramide or ketorolac may be the preferred (based on other migraineur's opinion). Of course, you need to discuss with your doctor which is the best choice for YOU, based on your individual medical history.

Source

Bajwa Z, Sabahat A. Preventive treatment of migraine in adults. In: UpToDate, Basow DS (Ed), UpToDate, Waltham, MA, 2013.

Colman I, Brown MD, Innes GD, Grafstein E, Roberts TE, Rowe BH. Parenteral metoclopramide for acute migraine: meta-analysis of randomised controlled trials. BMJ. 2004;329(7479):1369–1373.

Gilmore B, Michael M. Treatment of Acute Migraine Headache. Am Fam Physician. 2011 Feb 1;83(3):271-280.

Meredith JT, Wait S, Brewer KL. A prospective double-blind study of nasal sumatriptan versus IV ketorolac in migraine. Am J Emerg Med. 2003;21(3):173–175.

Friedman BW, Garber L, Yoon A, Solorzano C, Wollowitz A, Esses D et al. Randomized trial of IV valproate vs metoclopramide vs ketorolac for acute migraine. Neurology. 2014 Mar 18;82(11):976-83.

Silberstein SD, Holland S, Freitag F, et al. Evidence-based guideline update: pharmacologic treatment for episodic migraine prevention in adults: report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society. Neurology 2012; 78:1337.

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