What are the next steps in treating a severe migraine that has not responded to initial treatment with sumatriptan 1g IV?

Treatment for Severe Migraine Not Responding to Initial Therapy

For a severe migraine that has failed to respond to initial treatment, administer IV metoclopramide 10 mg plus IV ketorolac 30 mg as your next-line combination therapy. 1

Immediate Next Steps

First-Line Rescue Combination

• Administer IV metoclopramide 10 mg combined with IV ketorolac 30 mg as the most evidence-based rescue approach for severe migraine unresponsive to initial treatment 1
• This combination provides both direct analgesic effects through dopamine receptor antagonism (metoclopramide) and anti-inflammatory pain relief (ketorolac), with synergistic benefits 2, 1
• Ketorolac has rapid onset of action with approximately 6 hours duration and minimal risk of rebound headache 1

Alternative IV Options if Combination Fails

• IV prochlorperazine 10 mg can be substituted for metoclopramide with comparable efficacy for headache pain relief 1
• IV dihydroergotamine (DHE) is appropriate as monotherapy for refractory cases, particularly when other treatments have failed 2, 1
• IV metoclopramide alone (10 mg) has fair evidence as monotherapy and provides both antiemetic and direct analgesic effects 2

Critical Pitfalls to Avoid

What NOT to Use

• Avoid opioids - they should be reserved only when other medications cannot be used, sedation is not a concern, or abuse risk has been addressed 2
• Avoid IV corticosteroids - they are not effective for acute migraine treatment 2
• Avoid intranasal lidocaine - it is not effective for acute migraine 2

Medication Overuse Considerations

• If this patient is using acute medications more than twice weekly, consider that medication-overuse headache may be contributing to treatment failure 2
• Limit acute therapy to no more than 2 days per week to prevent medication-overuse headache 2

Rescue Medication Strategy

Home Rescue Plan

• For future attacks not responding to initial treatment, establish a "back-up plan" with rescue medications the patient can self-administer at home 2, 3
• Rescue medications (such as opioids or butalbital-containing compounds) permit relief without emergency department visits, though they may not completely eliminate pain 2
• This requires a cooperative arrangement between provider and patient with clear usage guidelines 2

When to Consider Different Medication Classes

• If the initial treatment provided partial response, a second dose of the same medication might be indicated 3
• When initial treatment provides no meaningful benefit, switch to a different medication class (e.g., if started with triptan, add NSAID; if started with NSAID, add triptan) 3

Long-Term Management Considerations

Indications for Preventive Therapy

• Initiate preventive therapy if this patient has ≥2 attacks per month producing disability lasting ≥3 days, uses abortive medication more than twice weekly, or has contraindication to/failure of acute treatments 2
• Preventive therapy should be strongly considered in this patient to reduce attack frequency and restore responsiveness to acute treatments 1

Evidence Quality Note

The guidelines cited are from the American College of Physicians (Annals of Internal Medicine, 2002) 2 and more recent evidence-based summaries (2025) 1. The 2025 Praxis Medical Insights guidelines, which synthesize recommendations from the American Academy of Family Physicians and American College of Physicians, provide the most current treatment algorithms and are prioritized here for the combination therapy approach.