What are the treatment options for headache in an inpatient setting?

From the Guidelines

Inpatient headache treatment should prioritize a multimodal approach, including intravenous NSAIDs like ketorolac, antiemetics such as metoclopramide or prochlorperazine, and migraine-specific agents like triptans or DHE, to effectively manage acute severe headaches and improve patient outcomes. When considering treatment options for headache in an inpatient setting, it's essential to tailor the approach to the specific headache type and severity. For acute severe headaches, intravenous medications are often the first line of treatment.

• NSAIDs like ketorolac (30mg IV every 6 hours) are effective for acute pain management, as supported by studies 1.
• Antiemetics such as metoclopramide (10mg IV every 8 hours) or prochlorperazine (10mg IV every 8 hours) are crucial in managing nausea and vomiting, which are common symptoms of migraine headaches, as noted in 1.
• Migraine-specific agents like triptans (e.g., sumatriptan) or DHE (1mg IV every 8 hours) may be used for migraine headaches, as recommended in 1. In refractory cases, continuous infusions of lidocaine (starting at 1-2mg/min) or propofol (starting at 30-40mg/hr) under close monitoring may be necessary. Hydration with IV fluids is essential, as is managing any contributing factors like medication overuse, stress, or sleep disturbances. Pain control should be reassessed frequently, with medication adjustments as needed. Non-pharmacological approaches, including a quiet, dark environment, cold compresses, and relaxation techniques, complement medication therapy. The goal of inpatient treatment is to break the headache cycle, identify triggers, and establish an effective outpatient management plan before discharge to prevent recurrence and reduce future hospitalizations, ultimately improving patient quality of life and reducing morbidity and mortality.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Treatment Options for Headache in an Inpatient Setting

• The treatment options for patients presenting with headache in the inpatient setting include intravenous fluids, anti-dopaminergic agents with diphenhydramine, steroids, divalproex, nonsteroidal anti-inflammatory drugs, intravenous dihydroergotamine, and nerve blocks 2.
• Other therapies such as ketamine and lidocaine are used with limited or inconsistent evidence 2.
• There is evidence for inpatient behavioral management therapy 2.
• Corticosteroids are commonly used as therapy for status migraine, and short courses of rapidly tapering doses of oral corticosteroids can alleviate status migraine 3.
• Intravenous corticosteroids can be used to break long-lasting migraine attacks, and corticosteroids have been used in the management of headache during the detoxification process as both outpatient treatments and inpatient settings 3.

Acute Migraine Treatment

• Nonsteroidal anti-inflammatory drugs (NSAIDs) and triptans are the mainstays of acute migraine therapy, and antiemetic drugs can be added as necessary 4.
• Dihydroergotamine (DHE) is also suitable for selected patients, and opioids and combination analgesics containing opioids should not be used routinely 4.
• Patient-specific clinical features should help guide the selection of an acute medication for an individual patient, and acute medications can be organized into four treatment strategies for use in various clinical settings 4.

Approach to the Workup and Management of Headache

• The challenge of headache management in the hospital can be divided into the diagnostic and management issues encountered in the emergency department, and the issues involved in the inpatient management of chronic refractory headaches 5.
• The problem of the intractable acute headache encountered in the emergency department can evolve into inpatient care of the same patient who has failed to respond to acute treatment 5.