From the Guidelines
Inpatient treatment for refractory acute migraine should prioritize a multimodal approach, focusing on abortive therapies such as dihydroergotamine, continuous intravenous lidocaine, intravenous magnesium sulfate, corticosteroids, neuroleptics, and intravenous ketamine, while also considering preventive therapies like CGRP monoclonal antibodies and gepants, as supported by the 2023 VA/DoD headache guideline 1.
When managing refractory acute migraine in an inpatient setting, the primary goal is to break the cycle of pain and restore function. The treatment strategy should be individualized, taking into account the patient's medical history, comorbid conditions, and previous responses to treatments.
- Abortive therapies:
- Dihydroergotamine (DHE) is often used as a first-line treatment, administered intravenously at 0.5-1mg every 8 hours for 2-3 days, preceded by antiemetics like metoclopramide 10mg IV or ondansetron 4mg IV to prevent nausea.
- Continuous intravenous lidocaine is another effective option, starting at 1-2mg/min and titrating up to 3-5mg/min as tolerated with cardiac monitoring.
- Intravenous magnesium sulfate (1-2g over 15 minutes) can be added for additional benefit.
- Preventive therapies:
- CGRP monoclonal antibodies, such as erenumab, fremanezumab, and galcanezumab, have a "strong for" recommendation for the prevention of episodic migraine (EM) and chronic migraine (CM) 1.
- Gepants, such as atogepant and rimegepant, have a "weak for" and "neither for nor against" recommendation, respectively, for the prevention of EM 1.
- Additional considerations:
- Corticosteroids such as dexamethasone 4mg IV every 6 hours for 1-2 days may help break the cycle.
- Neuroleptics like chlorpromazine 12.5-25mg IV every 6 hours or haloperidol 2-5mg IV can provide relief but require blood pressure monitoring.
- Intravenous ketamine at subanesthetic doses (0.1-0.5mg/kg/hr) is sometimes used for severe cases.
- Throughout hospitalization, patients should receive hydration, have triggers minimized, and maintain regular sleep patterns.
This aggressive, multimodal approach aims to break the refractory migraine cycle by targeting multiple pain pathways simultaneously, allowing the patient to transition back to outpatient management with preventive medications, as recommended by the 2023 VA/DoD headache guideline 1.
From the Research
Treatment Options for Refractory Acute Migraine in an Inpatient Setting
- The inpatient treatment of migraine is based on observational studies and expert opinion rather than placebo-controlled trials 2.
- Well-established inpatient treatments for migraine include dihydroergotamine, neuroleptics/antiemetics, lidocaine, intravenous aspirin, and non-pharmacologic treatment such as cognitive-behavioral therapy 2.
- In carefully monitored settings, the inpatient administration of intravenous lidocaine and ketamine can be successful in treating refractory chronic migraine 3.
- Triptans, ergot derivatives, and nonsteroidal anti-inflammatory drugs have historically been the main acute treatments for migraine, but new classes of acute treatment, including the small-molecule calcitonin gene-related peptide receptor antagonists and a 5-HT1F receptor agonist, are also available 4.
- Rescue therapy for acute migraine in the emergency department, urgent care, and headache clinic settings may include opioids, non-steroidal anti-inflammatory drugs (NSAIDs), and steroids, as well as post-discharge medications 5.
Medication Options
- Dihydroergotamine, neuroleptics/antiemetics, lidocaine, and intravenous aspirin are commonly used in inpatient settings 2.
- Triptans, such as sumatriptan, are effective for moderate to severe migraine, but should be avoided in patients with vascular disease, uncontrolled hypertension, or hemiplegic migraine 4, 6.
- Opioids, such as meperidine, tramadol, and nalbuphine, may be used for rescue therapy, but can have side effects such as dizziness, sedation, and nausea 5.
- NSAIDs, such as ketorolac, may provide benefit even when given late in the migraine attack, and corticosteroids can be useful in reducing headache recurrence after discharge 5.