What intravenous (IV) medications can be given to a patient with a migraine who has already taken acetaminophen (Tylenol) and ibuprofen?

IV Medications for Migraine After Failed Oral Analgesics

For patients with migraine who have failed acetaminophen and ibuprofen, the first-line IV therapy is metoclopramide 10 mg IV combined with ketorolac 60 mg IM/IV. 1

First-Line IV Combination Therapy

• Metoclopramide 10 mg IV plus ketorolac 60 mg IM/IV is the recommended first-line combination for severe, refractory migraine in the emergency setting. 1
• Metoclopramide works directly on migraine pain independent of other agents, not just as an antiemetic, with proven efficacy for both pain and nausea relief within 30-60 minutes. 2
• Ketorolac dosing can be repeated every 15-30 minutes up to a maximum of 120 mg per day, with treatment duration not exceeding 5 days. 3
• Metoclopramide should be given 20-30 minutes before or with the NSAID for optimal effect. 3

Alternative IV Options If First-Line Fails

• Prochlorperazine IV is the primary alternative if metoclopramide fails or is contraindicated. 1
• Prochlorperazine 25 mg can be given orally or as suppository, with a maximum of three doses per 24 hours. 3
• Dihydroergotamine (DHE) IV is another alternative for refractory cases. 1, 4

Specific Contraindications to Monitor

• Ketorolac is contraindicated in aspirin/NSAID-induced asthma, pregnancy, and cerebrovascular hemorrhage. 3
• Metoclopramide is contraindicated in pheochromocytoma, seizure disorders, GI bleeding, and GI obstruction. 3
• Prochlorperazine is contraindicated with CNS depression and use of adrenergic blockers. 3

Critical Adverse Effects to Anticipate

• Metoclopramide can cause dystonic reactions, restlessness, and drowsiness. 3
• Ketorolac may cause edema, drowsiness, dizziness, GI upset, and increased diaphoresis. 3
• Prochlorperazine carries risk of akathisia, pseudo-parkinsonism, tardive dyskinesia, and dystonia. 3

What NOT to Use

• Meperidine (Demerol) 50-150 mg IM/IV is available but NOT recommended as routine therapy due to risks of hypotension, respiratory depression, and potential for medication overuse headache. 3
• Opioids should not be used routinely for acute migraine treatment due to serious adverse events and risk of medication overuse. 5, 4

Status Migrainosus Consideration

• For status migrainosus (severe continuous migraine lasting up to one week), parenteral steroids and IV fluid supplementation are first-choice treatments. 3, 5
• Dexamethasone IV can be considered for prolonged attacks, though evidence for routine acute migraine is inadequate. 4

Critical Pitfall to Avoid

• Limit all acute medications to no more than 2 days per week (10 days per month) to prevent medication-overuse headache. 1
• Patients using acute medications more frequently should be evaluated for preventive therapy. 1