What is the recommended treatment for acute migraine in an urgent care setting without intravenous (IV) access?

Acute Migraine Treatment in Urgent Care Without IV Access

For acute migraine in urgent care settings without IV access, administer intramuscular (IM) ketorolac 60 mg combined with IM prochlorperazine 10 mg as first-line therapy, or use subcutaneous sumatriptan 6 mg for the most rapid and effective relief. 1

Primary IM Treatment Options

First-Line IM Combination Therapy

• Ketorolac 60 mg IM plus prochlorperazine 10 mg IM provides effective acute migraine relief with minimal risk of rebound headache. 1
• Ketorolac has rapid onset of action with approximately six hours of duration, making it ideal for severe migraine abortive therapy 1
• Prochlorperazine effectively relieves headache pain and has been shown comparable to metoclopramide in efficacy, with a more favorable side effect profile (21% adverse events versus 50% with chlorpromazine) 1
• This combination addresses both pain and nausea without requiring IV access 1

Most Effective Single Agent: Subcutaneous Sumatriptan

• Subcutaneous sumatriptan 6 mg is the most effective and rapidly acting option available, providing pain relief in 70-82% of patients within 15 minutes and complete pain relief in 59% by 2 hours. 1, 2, 3
• This represents the highest efficacy rate among all routes of triptan administration, with an NNT of 2.3 1, 3
• Peak blood concentrations are reached in approximately 15 minutes, faster than any other migraine-specific medication 1
• The standard dose is 6 mg subcutaneously at migraine onset, with a maximum of two doses in 24 hours separated by at least 1 hour 2
• A lower 4 mg dose may be used if side effects are dose-limiting, though efficacy is reduced 2

Alternative IM Option: Dihydroergotamine (DHE)

• IM dihydroergotamine is FDA-approved for acute migraine treatment and has good evidence for efficacy and safety as monotherapy 1, 4
• Consider DHE when patients have contraindications to NSAIDs or triptans 1

Contraindications and Safety Considerations

Ketorolac Precautions

• Use with caution in patients with renal impairment, history of GI bleeding, or heart disease 1
• Contraindicated in patients with creatinine clearance <30 mL/min, aspirin/NSAID-induced asthma, or active GI bleeding 1

Sumatriptan Contraindications

• Do not administer to patients with ischemic coronary artery disease, history of myocardial infarction, coronary artery vasospasm, uncontrolled hypertension, or peripheral vascular disease. 2
• Contraindicated in patients with history of stroke or TIA, hemiplegic or basilar migraine 2
• Avoid in patients with Wolff-Parkinson-White syndrome or other cardiac accessory conduction pathway disorders 2
• Cannot be used within 24 hours of ergotamine-containing medications or other 5-HT1 agonists 2
• Cannot be used concurrently with MAO-A inhibitors or within 2 weeks of discontinuing MAO-A inhibitors 2

Prochlorperazine Precautions

• Carries risks of tardive dyskinesia, hypotension, tachycardia, and arrhythmias 1
• Contraindicated in CNS depression and use of adrenergic blockers 1

Treatment Algorithm

Step 1: Assess for Contraindications

• Screen for cardiovascular disease, uncontrolled hypertension, and recent use of ergotamines or MAO inhibitors before considering sumatriptan 2
• Check renal function and GI bleeding history before administering ketorolac 1

Step 2: Choose Route Based on Severity and Patient Factors

• For moderate to severe migraine with rapid relief needed: Subcutaneous sumatriptan 6 mg 1, 2, 3
• For moderate to severe migraine when triptans contraindicated: Ketorolac 60 mg IM plus prochlorperazine 10 mg IM 1
• For patients with significant nausea or vomiting: Consider adding or using prochlorperazine as it provides both antiemetic and analgesic effects 1

Step 3: Consider Second Dose if Needed

• If using sumatriptan and some response is observed but pain returns, a second 6 mg dose may be given at least 1 hour after the first dose, with maximum cumulative dose of 12 mg in 24 hours 2
• Only consider a second dose if there was some response to the first injection 2

Critical Pitfalls to Avoid

Medication Overuse Headache

• Limit acute therapy to no more than twice weekly to prevent medication-overuse headache, which can lead to daily headaches and treatment resistance. 1, 5
• If patients require acute treatment more than twice weekly, transition to preventive therapy 1, 5

Avoiding Opioids

• Do not use opioids (hydromorphone, oxycodone) as they lead to dependency, rebound headaches, and eventual loss of efficacy 1
• Opioids should only be reserved for cases where all other medications cannot be used and risk for abuse has been addressed 1

Early Administration

• Administer treatment as early as possible during the attack to improve efficacy 1
• Triptans are most effective when taken early while headache is still mild 5

When to Escalate or Refer

• If patient fails to respond after 2-3 migraine episodes treated with first-line therapy, try a different triptan (failure of one does not predict failure of others) 1, 5
• If headaches occur more than twice weekly despite optimized acute therapy, initiate preventive therapy with propranolol 80-240 mg/day or topiramate 100 mg/day 5
• Reconsider diagnosis if patient has no response to first migraine attack treated with sumatriptan 2