From the Guidelines
For an inpatient with migraine who doesn't take regular migraine medications, the most effective treatment approach is to start with a combination of IV or IM medications, prioritizing NSAIDs as first-line medication, as recommended by the most recent and highest quality study 1. The treatment should begin with an NSAID such as ketorolac 30mg IV/IM, paired with an antiemetic like metoclopramide 10mg IV or prochlorperazine 10mg IV, to address both pain and nausea. Adding diphenhydramine 25-50mg IV can help prevent akathisia from the antiemetics. If this approach is insufficient, consider IV magnesium sulfate 1-2g over 15 minutes or dexamethasone 10mg IV as adjuncts, as these can help stabilize neuronal membranes and reduce inflammation. For severe, refractory cases, sumatriptan 6mg subcutaneously may be appropriate if there are no cardiovascular contraindications, as it is a migraine-specific abortive therapy. Ensuring the patient is in a quiet, dark room with adequate hydration is also crucial for managing migraine symptoms. After acute treatment, discussing preventive options before discharge, including beta-blockers, anticonvulsants, or antidepressants, can help reduce the frequency and severity of future migraine attacks, as suggested by 1 and 1. This multimodal approach targets different migraine pathways, providing a comprehensive treatment plan for inpatients with migraine who do not take regular migraine medications. Key points to consider in treatment choices include:
- Headache severity
- Migraine frequency
- Associated symptoms
- Comorbidities, as outlined in 1, although this study is less recent, its points on comprehensive assessment remain relevant. However, the primary guidance comes from the most recent studies 1, emphasizing the use of NSAIDs as first-line treatment and the importance of a multimodal approach in managing migraine symptoms effectively.
From the FDA Drug Label
DOSAGE AND ADMINISTRATION 2. 1 Dosing Information The recommended dose of sumatriptan tablets is 25 mg, 50 mg, or 100 mg. For an inpatient with migraine who does not take regular migraine medications, the recommended initial dose of sumatriptan is 25 mg, 50 mg, or 100 mg.
- The dose can be repeated after at least 2 hours if the migraine has not resolved or returns after a transient improvement.
- The maximum daily dose is 200 mg in a 24-hour period 2.
From the Research
Treatment Options for Inpatient Migraine
- Inpatient treatment of migraine is based on observational studies and expert opinion rather than placebo-controlled trials 3.
- Well-established inpatient treatments for migraine include dihydroergotamine, neuroleptics/antiemetics, lidocaine, intravenous aspirin, and non-pharmacologic treatment such as cognitive-behavioral therapy 3.
- Short-acting treatments possibly associated with medication overuse, such as triptans, opioids, or barbiturate-containing compounds, are generally avoided 3.
Alternative Treatment Approaches
- Metoclopramide, which is commonly used as an antiemetic, also seems to have pain-relieving effects for migraine and can be considered as first-line medication for migraine attacks in ED settings 4.
- Nonsteroidal anti-inflammatory drugs (NSAIDs) are recommended for mild to moderate migraine attacks, while migraine-specific agents (triptans and dihydroergotamine) are recommended for more severe attacks or when NSAIDs have consistently failed to respond 5.
Inpatient Management Strategies
- The goals of inpatient treatment include breaking the current cycle of headache pain, reducing the frequency and/or severity of future attacks, monitored detoxification of overused medications, and reducing disability and improving quality of life 6.
- Common treatments for inpatients include intravenous fluids, anti-dopaminergic agents with diphenhydramine, steroids, divalproex, nonsteroidal anti-inflammatory drugs, intravenous dihydroergotamine, and nerve blocks 7.
- Inpatient behavioral management therapy is also an effective approach for managing migraine 7.