What strong medication could be given for a headache due to Intravenous Immunoglobulin (IVIG) infusion?

Management of Headaches Due to IVIG Infusion

For headaches due to IVIG infusion, acetaminophen 1000 mg or ibuprofen 400 mg are the recommended first-line treatments, with sumatriptan as an effective second-line option for more severe cases. 1, 2

First-Line Treatment Options

• Acetaminophen 1000 mg: Recommended as a first-line treatment for headaches, including those associated with IVIG infusion 1, 3
• Ibuprofen 400 mg: Equally effective first-line option with significant improvement in pain response 1, 4
• Aspirin-acetaminophen-caffeine combination: Strong recommendation for migraine-like headaches that may occur with IVIG 1

Second-Line Treatment Options

• Sumatriptan (oral or subcutaneous): Strongly recommended for more severe headaches that don't respond to first-line treatments 1, 2
• Rizatriptan or zolmitriptan (oral or intranasal): Alternative triptans that can be effective for IVIG-induced headaches 1

Prevention Strategies

• Hydration: Ensuring adequate hydration before and during IVIG infusion can help reduce headache incidence 2
• Slower infusion rate: Decreasing the IVIG infusion rate can significantly reduce headache severity 5, 2
• Premedication: Administering acetaminophen and diphenhydramine before IVIG infusion 1

Treatment Algorithm

1. Pre-infusion:

   • Administer acetaminophen 650 mg and diphenhydramine before IVIG infusion 1
   • Ensure adequate hydration 2

2. During infusion:

   • If headache develops, administer acetaminophen 1000 mg or ibuprofen 400 mg 1, 3
   • Consider slowing the infusion rate 5, 2

3. For persistent/severe headache:

   • Administer sumatriptan (oral or subcutaneous) 1, 2
   • Consider aspirin-acetaminophen-caffeine combination 1

Alternative Administration Options

• Subcutaneous immunoglobulin (SCIG): Consider as an alternative to IVIG in patients with recurrent severe headaches, as it causes significantly less severe headaches (peak VAS score 1mm vs 11mm with IVIG) 5

Important Considerations

• Avoid opioids if possible due to risk of dependence and medication overuse headache 3
• Monitor for medication overuse headache if frequent treatment is required 3
• IVIG-induced headaches typically peak around day 4 of treatment 5
• Consider switching to an alternative IVIG product if headaches persist despite treatment 2

Special Situations

• For patients with history of migraines, consider prophylactic treatment with propranolol before IVIG infusion 2
• For severe refractory headaches, dihydroergotamine may be considered as a rescue medication 2