What are the options for intravenous (IV) migraine treatment without opiates or Benadryl (diphenhydramine)?

IV Migraine Treatment Options Without Opiates or Diphenhydramine

For IV migraine treatment without opiates or diphenhydramine, NSAIDs (particularly ketorolac), metoclopramide, prochlorperazine, and dihydroergotamine (DHE) are the most effective first-line options. 1, 2

First-Line IV Treatment Options

• NSAIDs: Ketorolac (Toradol) is the primary parenteral NSAID with relatively rapid onset of action and approximately six hours of duration, making it ideal for severe migraine abortive therapy with minimal risk of rebound headache 1

• Antiemetics as Primary Treatment:

  • Metoclopramide (10 mg IV) - effective not only for treating accompanying nausea but also provides synergistic analgesia for migraine pain 1, 3
  • Prochlorperazine (10 mg IV) - effectively relieves headache pain and has been shown to be comparable to metoclopramide in efficacy 1, 4

• Dihydroergotamine (DHE): Intranasal or IV DHE has good evidence for efficacy and safety as monotherapy for acute migraine attacks 1, 2

Second-Line Options

• Corticosteroids: While not recommended as first-line treatment for routine migraine attacks, steroids are beneficial for status migrainosus (severe, continuous migraine lasting up to a week) 5

• Valproate Sodium Injection: Can be used as an IV alternative when oral administration is not feasible, particularly for patients with epilepsy who also have migraine 6

  • Caution: Valproate has significant contraindications including pregnancy risk and potential for hepatic dysfunction and pancreatitis 6

• Intranasal lidocaine: May provide relief for acute migraine, though evidence is limited and inconsistent regarding recurrent headaches 1

Treatment Algorithm

1. For mild to moderate migraine:

   • Start with IV ketorolac 30 mg 1, 2

2. For moderate to severe migraine or if ketorolac is ineffective:

   • IV metoclopramide 10 mg (higher doses of 20-40 mg show no additional benefit) 3
   • OR IV prochlorperazine 10 mg 4
   • Consider adding IV ketorolac if not already administered 1, 2

3. For severe migraine unresponsive to above treatments:

   • IV or intranasal DHE 1, 2
   • Consider IV corticosteroids, particularly if status migrainosus is suspected 5

4. For migraine with significant nausea/vomiting:

   • Prioritize IV metoclopramide or prochlorperazine as first-line treatment 1, 3, 4

Important Considerations

• Avoid medications containing opiates as they can lead to dependency, rebound headaches, and eventual loss of efficacy, particularly in chronic daily headaches 1

• Be vigilant about medication overuse headache, which can result from frequent use of acute medications (more than twice weekly) 2

• Monitor for common adverse effects:

  • Akathisia can occur with metoclopramide or prochlorperazine (occurred in approximately 33 patients in one study) 3
  • Drowsiness is common with many migraine treatments 3

• For patients with contraindications to vasoconstricting drugs (like triptans), focus on NSAIDs and antiemetics 7

• Consider the patient's history of response to previously used medications and the usual rapidity of pain intensity increase when selecting treatment 7