Inpatient Management of Headaches
For acute migraine in the inpatient setting, initiate combination therapy with IV ketorolac (30mg) plus IV metoclopramide (10mg) as first-line treatment, as this provides superior pain relief compared to monotherapy while minimizing rebound headache risk. 1
First-Line Inpatient Treatment Protocol
Combination therapy is the cornerstone of inpatient migraine management:
- IV ketorolac 30mg provides rapid onset analgesia with approximately 6 hours duration and minimal rebound headache risk 1
- IV metoclopramide 10mg treats both nausea and provides synergistic migraine analgesia 1
- This combination is more effective than either agent alone and should be initiated early in the attack 1
- Consider adding diphenhydramine with metoclopramide to reduce extrapyramidal side effects 1
Second-Line Options for Refractory Cases
When first-line therapy fails, escalate to:
- IV dihydroergotamine (DHE) has strong evidence for efficacy and safety as monotherapy for acute migraine attacks 1, 2
- DHE demonstrated 48-70% headache response rates at 4 hours in controlled trials 2
- Divalproex sodium IV can be used for status migrainosus 3
- Nerve blocks (occipital or trigeminal) may provide additional relief 3
Special Considerations for Severe Presentations
For patients with severe nausea/vomiting:
- Use non-oral routes exclusively (IV, subcutaneous, or intranasal formulations) 4, 1
- Administer antiemetics alongside analgesics when nausea is prominent 1
- Avoid dopamine antagonist antiemetics (metoclopramide, prochlorperazine) in patients with Parkinson's disease 1
For status migrainosus (headache >72 hours):
- IV fluids for hydration 3
- Corticosteroids (dexamethasone or methylprednisolone) to break the cycle 3
- Consider continuous IV DHE protocol for refractory cases 3
Medications to Strictly Avoid
Never use the following in inpatient migraine management:
- Opioids (including hydromorphone) lead to dependency, rebound headaches, and lack efficacy evidence 4, 1
- Butalbital-containing compounds cause medication overuse headache with limited efficacy 4, 1
- These agents worsen long-term outcomes and should be avoided regardless of pain severity 4
Critical Pitfalls to Avoid
Medication overuse headache prevention:
- Limit acute medication use to no more than twice weekly to prevent transformation to chronic daily headache 4, 1
- Threshold varies by agent: ≥15 days/month for NSAIDs, ≥10 days/month for triptans 4
- Patients overusing opiates, barbiturates, or benzodiazepines require slow tapering and possibly continued inpatient treatment to prevent acute withdrawal 5
Red flags requiring urgent neuroimaging:
- Thunderclap onset (sudden, severe, maximal at onset) 6
- New neurologic deficits on examination 4
- Headache worsened by Valsalva maneuver 4
- New onset in patients >50 years old 7
- Progressive worsening pattern 4
- Presence of cancer or immunosuppression 7
Transition to Preventive Therapy
Initiate preventive therapy discussion during hospitalization if:
- Patient experiences ≥2 migraine attacks per month causing disability lasting ≥3 days 4
- Acute treatments are contraindicated or ineffective 4
- Patient uses abortive medications more than twice weekly 4
- Evidence supports topiramate, propranolol, metoprolol, amitriptyline, or CGRP monoclonal antibodies for prevention 4
Adjunctive Inpatient Strategies
Behavioral and supportive measures:
- IV hydration for all patients 3
- Quiet, dark room environment to minimize sensory triggers 4
- Consider inpatient behavioral management therapy for refractory cases 3
- Address comorbid conditions (depression, anxiety, sleep disorders) that impair treatment effectiveness 5
Discharge Planning
Before discharge, ensure:
- Rescue medication plan for home use when outpatient treatments fail 4
- Education about medication overuse headache thresholds 4
- Lifestyle modification counseling: hydration, regular meals, sufficient sleep, regular aerobic exercise, stress management 4
- Follow-up scheduled within 2-4 weeks to assess response and adjust preventive therapy 5