What is the best course of action for a 30-year-old female with a 5-day intractable migraine (resistant to oral and intravenous (IV) medications) and a non-pruritic rash on her chest?

Immediate Evaluation for Secondary Causes

This patient requires urgent evaluation for secondary headache causes, specifically meningitis or other CNS infection, given the combination of intractable headache resistant to standard therapies and new-onset rash. 1, 2

The presence of a non-pruritic rash on the chest alongside a 5-day intractable migraine that has failed both oral and IV medications is a red flag that demands immediate investigation for serious underlying pathology before proceeding with further migraine-specific treatment.

Critical Red Flags Requiring Immediate Workup

• Perform a complete neurological examination and assess for meningeal signs (neck stiffness, photophobia, fever) as the combination of severe headache with rash raises concern for meningococcemia, viral meningitis, or other infectious/inflammatory CNS processes 1, 2
• Check vital signs including temperature - fever with headache and rash constitutes a medical emergency requiring immediate lumbar puncture and blood cultures 1
• Examine the rash characteristics carefully - distribution, morphology, and evolution can help differentiate between benign causes (viral exanthem, drug reaction) and life-threatening conditions (meningococcemia, Rocky Mountain spotted fever, vasculitis) 1

If Secondary Causes Are Ruled Out: Status Migrainosus Management

Once infectious, inflammatory, and other secondary causes are excluded, this represents status migrainosus (migraine lasting >72 hours despite treatment).

Immediate IV Treatment Protocol

• Administer IV metoclopramide 10 mg PLUS IV ketorolac 30 mg as the first-line combination therapy for severe refractory migraine in the emergency setting 1, 2
• This combination provides rapid pain relief through complementary mechanisms: metoclopramide offers direct analgesic effects via central dopamine receptor antagonism while ketorolac provides anti-inflammatory analgesia with 6-hour duration 1
• Add IV fluids as dehydration commonly accompanies prolonged migraine and impairs medication absorption 2

Second-Line IV Options if Initial Treatment Fails

• Consider IV dihydroergotamine (DHE) 0.5-1.0 mg if the metoclopramide/ketorolac combination provides inadequate relief after 1-2 hours 1, 2
• DHE has strong evidence for efficacy in refractory migraine but requires careful screening for cardiovascular contraindications 1, 2
• Avoid opioids and butalbital-containing compounds as they have questionable efficacy, lead to dependency, cause rebound headaches, and worsen long-term outcomes 1, 2

Critical Next Step: Initiate Preventive Therapy

• This patient requires immediate initiation of preventive therapy given the severity and duration of this attack, which indicates high-frequency or severe episodic migraine 1, 3, 4
• First-line preventive options include propranolol 80-240 mg/day, topiramate (titrated to therapeutic dose), or amitriptyline 30-150 mg/day 1, 5
• The goal is to prevent progression to chronic migraine (≥15 headache days per month), which carries substantially greater disability and is more difficult to treat 3, 4

Addressing the Rash

• If the rash is determined to be unrelated to serious pathology, consider whether it represents a drug reaction from the multiple medications already tried 1
• Document the rash characteristics, timing relative to medication administration, and any associated symptoms 1
• Avoid diphenhydramine as a routine antihistamine in migraine treatment unless there is clear evidence of allergic reaction, as it can cause sedation without addressing the underlying migraine pathophysiology 1

Critical Pitfall to Avoid

• Do not discharge this patient without a clear preventive therapy plan and close follow-up - a 5-day intractable migraine indicates treatment failure and high risk for chronic migraine development 1, 3, 4
• Strictly limit all acute migraine medications to no more than 2 days per week once the current attack resolves, as medication overuse headache (MOH) may be contributing to treatment resistance 1, 2, 3
• The patient needs education that frequent acute medication use (>10 days/month for triptans, >15 days/month for NSAIDs) paradoxically worsens migraine frequency and creates a cycle of chronic daily headache 1, 3