What is the next step for a patient with a history of chronic migraine who has had a migraine for 2 weeks without resolution, despite trying Toradol (ketorolac) 60mg intramuscular (IM) injection and Kenalog (triamcinolone) 40mg injection with only 4 hours of relief, and Maxalt (rizatriptan) 2 doses without any relief?

Status Migrainosus: Immediate Escalation to Parenteral Therapy Required

This patient has status migrainosus (migraine lasting >72 hours despite treatment) and requires immediate escalation to parenteral dihydroergotamine (DHE) or combination IV therapy with metoclopramide plus ketorolac, as the failed response to both NSAIDs and triptans indicates need for more aggressive intervention. 1, 2, 3

Understanding the Clinical Situation

This patient meets criteria for status migrainosus—a debilitating migraine attack persisting beyond 72 hours (2 weeks in this case) with inadequate response to standard acute treatments 3. The temporary 4-hour relief from Toradol/Kenalog followed by recurrence, plus complete failure of Maxalt (rizatriptan), indicates:

• Medication-overuse headache (MOH) must be ruled out first 1. If this patient has been using acute medications more than 2 days per week for the past 3 months, MOH is likely contributing and all acute medications should be discontinued 1
• The migraine has entered a refractory state requiring parenteral therapy 3, 4
• Standard oral triptans are insufficient for this severity 1, 5

Immediate Treatment Algorithm

First-Line Parenteral Options (Choose One):

Option 1: IV Combination Therapy (Preferred for Emergency/Urgent Care Setting)

• Metoclopramide 10mg IV PLUS Ketorolac 30mg IV 2, 6
• This combination provides both direct analgesic effects and addresses gastric stasis that impairs medication absorption during migraine 2
• Can repeat ketorolac every 6 hours if needed (maximum 5 days) 2
• Metoclopramide provides synergistic analgesia beyond just treating nausea 2, 6

Option 2: Dihydroergotamine (DHE)

• DHE 0.5-1.0mg IV or intranasal DHE 1, 2, 7, 3
• Superior to oral ergotamines with better safety profile 1
• Intranasal DHE shows 47-48% headache response at 4 hours 7
• Critical contraindication check: Cannot use if patient took rizatriptan within past 24 hours due to risk of vasospasm 6, 4
• Also contraindicated with uncontrolled hypertension, coronary artery disease, concurrent beta blockers, SSRIs, or macrolides 6

Second-Line: Subcutaneous Sumatriptan

• Sumatriptan 6mg subcutaneous if oral rizatriptan failed 6, 3, 4
• Provides 59% complete pain relief at 2 hours—highest efficacy of any triptan formulation 2
• Bypasses gastric absorption issues 4
• Different route may succeed where oral triptan failed 2, 8

Critical Next Steps Beyond Acute Treatment

Initiate Preventive Therapy Immediately

This patient absolutely requires preventive therapy given the 2-week duration and failure of multiple acute treatments 1. The guidelines are clear:

• Preventive therapy is indicated when migraine continues to impair quality of life despite optimized acute therapy 1
• Patients requiring acute medication more than 2 days per week need prevention 1
• Do not wait to see if acute treatment works—start prevention now 1

First-line preventive options:

• Topiramate, propranolol, or amitriptyline for episodic migraine 1
• OnabotulinumtoxinA is the only FDA-approved preventive for chronic migraine if patient meets chronic migraine criteria (≥15 headache days/month for >3 months with ≥8 migraine days/month) 1, 9
• CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab) are third-line options 1

Assess for Medication Overuse Headache

• If patient has been using any acute medications ≥10 days/month (or ≥15 days/month for simple analgesics) for >3 months, this IS medication-overuse headache 1
• Requires complete withdrawal of overused medications 1
• Bridge therapy with preventive medication during withdrawal period 1

Common Pitfalls to Avoid

1. Do not prescribe opioids or butalbital compounds 1, 2. While they may provide temporary relief, they worsen the cycle of medication overuse and are associated with transformation to chronic daily headache 1, 5

2. Do not allow patient to continue frequent acute medication use without prevention 1. This creates a vicious cycle where increasing headache frequency leads to more medication use, which perpetuates the problem 1, 2

3. Do not use DHE and triptans within 24 hours of each other 6, 4. This combination risks severe vasospasm 6

4. Do not assume corticosteroids (like the Kenalog already given) are effective for acute migraine 1, 2. Prednisone and other corticosteroids have limited evidence for acute treatment and are more appropriate for status migrainosus as adjunctive therapy, not monotherapy 2, 3

Disposition and Follow-Up

• If outpatient management attempted and fails within 24-48 hours, hospital admission for IV DHE protocol may be necessary 3, 4
• Schedule follow-up within 1 week to assess preventive therapy response 1
• Provide headache diary to track frequency and identify triggers 1, 8
• Set realistic expectations: preventive therapy requires 2-3 months for oral agents to show efficacy 1