What injections are used for migraine pain management?

Injectable Treatments for Migraine Pain Management

Subcutaneous sumatriptan (6 mg) is the most effective injectable treatment for acute migraine pain, providing rapid relief within 15 minutes and should be considered first-line injectable therapy for severe migraine attacks. 1, 2

First-Line Injectable Options

Sumatriptan (Imitrex) Injection

• Dosage: 6 mg subcutaneous injection
• Efficacy: 70-82% of patients experience relief within 1-2 hours 1, 3
• Onset: Fastest onset of all migraine medications (peak concentration in ~15 minutes) 1
• Indications:
  • Acute treatment of migraine attacks with or without aura
  • Acute treatment of cluster headache episodes 2
• Administration: Self-administered using autoinjector device
• Contraindications:
  • Ischemic heart disease or coronary artery vasospasm
  • Uncontrolled hypertension
  • History of stroke or TIA
  • Hemiplegic or basilar migraine
  • Use within 24 hours of ergotamine derivatives or other triptans 2

Dihydroergotamine (DHE)

• Formulation: Available in parenteral preparations
• Efficacy: Effective for severe migraines
• Best use: More appropriate for severe migraines than oral ergotamine preparations 1
• Caution: Has oxytocic properties (contraindicated in pregnancy) 1

Second-Line Injectable Options

Ketorolac (Toradol)

• Dosage: 60 mg IM every 15-30 minutes (maximum 120 mg per day)
• Duration: Approximately 6 hours
• Best use: Abortive therapy for severe migraines when triptans are contraindicated
• Advantage: Low risk of rebound headache 1
• Limitations: Treatment not to exceed 5 days 1

Opioid Analgesics

• Examples: Meperidine (Demerol), Butorphanol (Stadol) nasal spray
• Role: Reserved for severe migraines unresponsive to other treatments
• Important caution: Should be avoided for chronic daily headaches due to:
  • Risk of dependency
  • Rebound headaches
  • Loss of efficacy with continued use 1

Nerve Blocks

Greater Occipital Nerve Block

• Evidence: Recommended for short-term treatment of migraine 1
• Efficacy: Provides rapid relief for some patients
• Limitation: Insufficient evidence for prevention of chronic migraine 1

Algorithm for Injectable Migraine Treatment

1. For acute severe migraine attacks:

   • First choice: Subcutaneous sumatriptan 6 mg (if no contraindications)
   • Alternative if sumatriptan fails: Second dose after 1 hour (maximum 2 doses/24 hours) 2

2. For patients with contraindications to triptans:

   • First choice: Ketorolac 60 mg IM
   • Alternative: Greater occipital nerve block

3. For cluster headaches:

   • First choice: Subcutaneous sumatriptan 6 mg or intranasal zolmitriptan 10 mg 1
   • Alternative: Normobaric oxygen therapy 1

4. For rescue therapy (when other treatments fail):

   • Consider opioid analgesics (with caution regarding dependency)
   • Use as home rescue medication to avoid emergency department visits 1

Common Pitfalls and Caveats

1. Medication overuse headache: Limit injectable treatments to no more than 2 times per week to prevent medication overuse headache 1

2. Recurrence: Approximately 40% of patients experience headache recurrence within 24 hours after initial response to sumatriptan 3

3. Adverse reactions:

   • Injection site reactions occur in approximately 30% of patients with subcutaneous sumatriptan 3
   • Chest symptoms occur in 3-5% of patients and require immediate medical attention if severe 2, 3

4. Cardiovascular risk: Carefully screen patients for cardiovascular risk factors before prescribing triptans 2

5. Pregnancy considerations: Avoid ergot derivatives during pregnancy due to oxytocic properties 1

By following this evidence-based approach to injectable migraine treatments, clinicians can provide effective pain relief while minimizing risks and complications, ultimately improving patient outcomes in terms of morbidity, mortality, and quality of life.