It’s day three of a miserable migraine attack that just won’t break. You’re having a hard time keeping any food down and staying hydrated from vomiting. You’re dreading having to go into the loud bright ER (emergency room), wait a few hours in the waiting room, eventually brought back to be accused of drug seeking, asked, “what do you want me to do” (ummm, you’re the doctor you’re thinking to yourself), and written off with some Tylenol. It’s frustrating and demeaning.
What should you ask for in the ER for a bad migraine?
So what is the best thing to ask for in the ER for a bad migraine attack? My advice is to start the conversation by saying you are having a severe migraine and you do NOT want narcotics/opiates. This will help to quickly diffuse the unfortunate common knee-jerk prejudice of drug seekers that many ER docs have when headache or pain patients come into the ER. Then, tell them your doctor told you to come in for an IV (intravenous) “migraine cocktail” to try to break the migraine when this happens.
You may have heard the term “migraine cocktail” or “headache cocktail” and want to ask for it, but aren’t sure what to ask for. Many times the ER doctor may not know exactly what to put in it either. Well, that brings us to the purpose of this blog article. Print this blog out and take it with you next time you end up in the ER for a bad migraine, or show it on your phone.
What is the migraine cocktail in ER (headache cocktail in ER)?
The following medication combination is commonly used in the IV migraine cocktail in the ER, along with IV hydration. Your headache specialist or neurologist may be able to coordinate outpatient IV infusions for you in their infusion room if they have one to avoid a trip to the ER. Now keep in mind, these “ingredients” are not universally safe for everyone. The ER doctor will take your medical history and other home medications being used into account to decide which of the following medications are safe to use for you personally (although most patients have no major contraindications to these):
1) 2 grams Magnesium
2) 10 mg Metoclopramide (Reglan) or 10 mg Prochlorperazine (Compazine) (these are usually better for migraine compared to Ondansetron (Zofran))
3) 30 mg Ketorolac (Toradol) (or 60 mg intramuscular Ketorolac shot)
4) 4-8 mg Dexamethasone (Decadron) or 125-250 mg Methylprednisolone (Solu-Medrol)
5) 1 gram Divalproex (Depacon)
6) 25-50 mg Diphenhydramine (Benadryl) (they may avoid this one if you are driving since it can make you drowsy)
How is IV DHE given in the ER or in the hospital?
The migraine cocktail combination listed above may all be given, or the ER doctor may choose a few of them and then add the others if you are not improving. If the migraine is still bad following this migraine cocktail, DHE (Dihydroergotamine) is often going to be the next best step in breaking the status migrainosus (migraine lasting more than 3 days), or a resistant migraine that just isn’t going away. Your doctor will determine if DHE is safe for you based on your current medicines and medical history. For example, if you have cardiac, vascular, or stroke history (or uncontrolled risk factors for these diseases) it would be unsafe. Many times ER doctors aren’t comfortable or familiar with giving IV DHE. Patients are sometimes admitted to the hospital for the purpose of giving IV DHE, coordinated by a neurologist. However, some ER physicians are familiar with IV DHE, which is great for you. If they aren’t familiar with it, but are open to trying it for you, IV DHE is done according to Raskin’s IV DHE protocol as can be easily followed below:
(No triptans 24 hours before or after DHE!)
1) 30 minutes before IV DHE: Benadryl 25-50 mg + anti-nausea medicine (Reglan 10 mg vs. Compazine 10 mg vs. Zofran 4 mg)
2) 0.25 mg IV DHE (if 1st time) vs. 0.50 mg IV DHE (if have had before). Then, 0.25 mg IV DHE every 15 mins until 1 of the following happens:
-Headache resolves
-Severe nausea occurs
-Cumulative dose of 1 mg is reached
3) If admitted to the hospital for severe migraine, the maximum tolerated dose from above (up to 1 mg) can be given IV right at that dose every 8 hours with the Benadryl and anti-nausea medicine 30 mins prior, as outlined above. IV DHE is limited to 3 mg/day and this can be continued typically for 3 days if needed.
What is the home migraine cocktail (migraine rescue treatment)?
If you have migraine, you absolutely must have an abortive (as needed) migraine treatment. When your normal migraine abortive medications such as over the counter pain medicines, NSAIDS, triptans or gepants don’t stop the migraine, you need to have a rescue medication plan, which can be thought of as a home migraine cocktail. The goal of having a rescue or home migraine cocktail is to try to avoid the hassle of having to go to the ER all together by breaking the migraine at home.
You and your doctor should have a migraine rescue plan and either have the rescue medication available at home in case you need it, or call your doctor and request one of the following options if you have a migraine that just won’t break. As with the ER migraine cocktail, your doctor will ultimately decide if these options are safe for you to use with your medical history and other medicines you may be taking.
Here are some treatments that I most commonly use for migraine rescue at home, although there are certainly other options as well:
1) DHE is one of the only medicines that can still break a migraine after it’s been going on for days or weeks, and when allodynia or central sensitization sets in (when your hair and scalp are sore and hurt). DHE is often considered the most potent anti-migraine medicine. Nasal DHE such as the older Migranal or the newer and much more effective and easier to use Trudhesa. Notably, Trudhesa nasal DHE reaches IV blood levels of DHE within 30 minutes, minus many of the side effects often encountered with IV DHE. So having Trudhesa is almost the same as having IV DHE potency from the comfort of home, without having to go to the ER or be admitted to achieve those more effective DHE levels in the blood. Nasal DHE can be repeated every 8 hours up to 3 days if needed until the migraine breaks. Vials of DHE can also be prescribed to do self-injections with a syringe intramuscularly or subcutaneously every 8 hours up to 3 days as well, but it is certainly more complicated than a simple nasal spray. As with IV or any form of DHE, triptans cannot be used within 24 hours before or after DHE.
2) Steroids are commonly prescribed for a refractory migraine attack. They need to be taken with food, preferably earlier in the day, and not with other NSAIDs. I usually use one of the following:
-Medrol dose pack (usually a 5-day course)
-Decadron 4 mg pill: Take 1 pill three times daily on day 1, twice daily on day 2, once on day 3 (3-day course)
-Prednisone 10 mg: 5 pills (50 mg) once each morning for 5 days, then decrease by 10 mg each day until done (10-day course)
3) Toradol 10 mg pill taken every 8 hours (three times daily) with food until either the migraine breaks for 24 hours, or you’ve used it for 5 days max, whichever comes first. This must be taken with food and not with any other NSAIDs or steroids.
4) Divalproex (Depakote) ER 1000 mg at bedtime for 5 days, then 500 mg at bedtime for 5 days, then stop. A side note, if you are using Lamotrigine (Lamictal), you do not want to use this together.
5) Chlorzoxazone (Parafon Forte) 1000 mg every 6 hours (4 times daily) until either the migraine breaks for 24 hours, or you’ve used it for 5 days, whichever comes first.
How to prevent migraine attacks.
If you are having frequent migraines, or severe migraines that you often end up in the ER for, a migraine preventive treatment of some type is crucial. There are many newer great options with low side effects such as the once monthly self-injections or quarterly IV treatments of CGRP monoclonal antibodies (CGRP mAbs)(Aimovig (Erenumab), Ajovy (Fremanezumab), Emgality (Galcanezumab), Vyepti (Eptinezumab)), the gepants(Nurtec ODT (Rimegepant), Qulipta (Atogepant)), or the older historical options such as a daily pill from the antiseizure, antidepressant/anxiety and antihypertension (blood pressure) medication categories, Botox injections, neuromodulation devices, or alternative treatments such as vitamins and supplements, acupuncture, acupressure and pressure points, or yoga and meditation.
The goal of migraine preventive treatment is to lessen the frequency and/or severity of migraine attacks, prevent their disruption to life, and hopefully eliminate the need for those painful (pun intended) ER visits!
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