1. WAPA Winter Conference 2013 Headache Review
Sylvia Lucas MD, PhD
Clinical Professor of Neurology and Neurosurgery
Adjunct Rehabilitation Medicine
University of Washington Medical Center
January 29, 2013

2. IHS Classification 2nd Editon – ICHD II
Secondary HA
5. Posttraumatic
6. Vascular disease
7. Abnormal ICP, Neoplasm, etc
8. Substances
9. CNS infection
10. Metabolic
11. Cervicogenic, Eyes, Sinuses
12. Psychiatric HA
13. Neuralgias
14. Other
Primary HA
1. Migraine
2. Tension-type
3. Cluster and its relatives (TACs)
4. Other primary headaches (exertional, coital, hypnic, etc.)

3. AGE- AND GENDER-SPECIFIC PREVALENCE OF MIGRAINE
Lipton RB, Stewart WF. Neurology
Migraine Prevalence (%)
In both males and females, the prevalence distribution of migraine is an inverted U-shape curve. Prevalence rises through early adult life and then falls after middle life. The second important point to emphasize on this slide is that, at all post-pubertal ages, migraine is substantially more common in women than in men.
The prevalence of migraine varies as a function of age. Migraine is a disorder that is most prevalent between the ages of 25 and 55. Part of the reason the condition has such a big impact in the workplace is that it affects people during their peak productive years.
Lipton RB, Stewart WF. Migraine in the United States: a review of epidemiology and health care use. Neurology.1993;43(suppl 3):S6-S10.

4. Secondary Headache Warnings
“Worst or first”
New headache pattern
Change in headache pattern
Progressive headache syndrome
Onset with valsalva or intercourse
Papilledema or abnormal neurological exam
New headache over the age of 50
History of cancer or HIV

5. What kind of headache is this?
32 year old woman
Headache since age 12
Severe pain
Stabbing, jabbing
Knife through her eye
Nausea and vomiting
Scalp hurts
Light hurts
Sound hurts
Movement hurts
Stays in bed
Lasts hours
Can’t work
Misses 2 days of work
per month 5

6. Differentiating Migraine and Tension-Type Headaches
Usually lasts 4-72 hours
Moderate to severe
Often unilateral (60%), aura in a minority of patients
Exacerbated by routine activity
Nausea, vomiting, photophobia, and phonophobia are common
Tension type
Low impact
Usually bilateral, mild to moderate headache
Photo- or phonophobia sometimes present
No nausea or vomiting
Certain features can be used to differentiate migraine from tension-type headache.
Migraine is characterized by exacerbation by routine activity, moderate to severe intensity, unilateral presentation, and nausea and vomiting.
In contrast, tension-type headache is low impact, usually bilateral, and not accompanied by nausea or vomiting.
Dowson AJ, Lipscombe S, Sender J, Rees T, Watson D. New guidelines for the management of migraine in primary care. Curr Med Res Opin. 2002;18:
Dowson AJ et al. Curr Med Res Opin. 2002;18: 6

7. ONE-YEAR PREVALENCE OF COMMON HEADACHE DISORDERS%
Female
Male
This slide summarizes the one-year prevalence of some common primary headache disorders. By far, the most common headache disorder in the general population is episodic tension-type headache, which affects 40% of the population. These are the bilateral, pressing or squeezing headaches of everyday life that don’t have many accompanying features. Migraine is also a very common primary headache disorder affecting 18% of women and 67% of men.
Frequent headaches occur > 15 days per month and affect 5% of women and 2.8% of men. The two most common frequent headaches are chronic tension-type headache and transformed/chronic migraine, which will be discussed within the context of chronic daily headache.
Lipton RB, Stewart WF. Migraine in the United States: a review of epidemiology and health care use. Neurology.1993;43(suppl 3):S6-S10.
Schwartz B, Stewart WF, Simon D, Lipton RB. Epidemiology of tension-type headache. JAMA. 1998;279:
Scher AI, Stewart WF, Liberman J, Lipton RB. Prevalence of frequent headache in a population sample. Headache.1998;38:
(>15 attacks per month)
Lipton RB, Stewart WF. Neurology
Schwartz BS et al. JAMA
Scher AI et al. Headache 7

8. What causes headache? Genetics Environment
A headache brain is inherited
A headache brain is hypersensitive and hyperexcitable
If one parent has migraine: 50% chance that a child will have migraine
Environment
Internal and external triggers 8

9. Migraine is a Transmission Problem Same headache-different genes
FHM-I CACNA1A: P/Q voltage-gated Ca2+ channel on chr 19 (Ophoff et al. Cell 1996; 87: )
FHM-II ATP1A2: Na+/K+ ATPase on chr 1q23 (De Fusco et al. Nat Genetics 2003;33: )
FHM-III SCN1A: sodium channel gene on chr 2q24 (Dichgans et al., Lancet 2005;366: )
Effect of mutation (SCN5A) 2-4x accelerated recovery from fast inactivation

10. 10

11. Phases of a Migraine Headache
Pre-HA
Headache
Post-HA
Intensity
Moderate to Severe HA
Premonitory/
Prodrome
Aura
Mild
Postdrome
Time
Adapted from Cady RK. Clin Cornerstone. 1999;1(6):21-32. 11

12. Activation of the TNC May Result in Referred Pain that Could be Perceived Anywhere along the Trigeminocervical Network 12

13. Syndrome of Migraine: More than Pain
Neurologic
Gastrointestinal
Autonomic
Musculoskeletal
Mood
Pain

14. Migraine With Aura At least 2 attacks with at least 3 of the following
Fully reversible visual, sensory, or speech symptoms
At least 1 aura symptom that develops gradually over 5 minutes and/or different aura symptoms occuring in succession over 5 minutes
Each aura symptom lasts 5 minutes and no more then 60 minutes
Headache fulfills criteria for migraine without aura
Headache begins during aura or follows aura within 60 minutes
Not attributed to another disorder
Aura symptoms, if they are present, develop 15 to 60 minutes before the onset of headache. These symptoms are transient and commonly include visual signs such as slowly progressing geometric patterns. Migraine aura is believed to originate from the cerebral cortex and represent a cortical spreading depression, a short-lasting depolarization wave that moves across the cortex at a rate of 3 to 5 mm/min, producing gross alterations in ion balance. The relationship between the aura and the headache pain of migraine is not well understood.
Headache Classification Committee of the International Headache Society.
Cephalalgia. 2004;24(suppl 1):24-25.

15. About 15-18 % of migraine patients have aura
Cortical Spreading Depression
Fortification spectra

16. STRATEGIES FOR MIGRAINE TREATMENT
Acute
treatment
To stop pain
and prevent
progression
Silberstein SD. Cephalalgia
Establish diagnosis
Set realistic goals
Educate patients
Individualize care
Preventive
treatment
Decrease in
migraine frequency
warranted
Preemptive
treatment
Migraine trigger
time-limited and
predictable
Treatment can be acute, preemptive, or preventive.
Acute treatment is initiated during an attack to relieve pain and disability and to stop progression of the attack.
Preemptive treatment is used when a known headache trigger exists, such as exercise or sexual activity, and for patients experiencing a time-limited exposure to a trigger, such as ascent to a high altitude or menstruation.
Preventive treatment is maintained for months or even years to reduce attack frequency, severity, and duration.
Patients taking preventive medication can also use acute and preemptive medication.
Silberstein SD. Preventive treatment of migraine: an overview. Cephalalgia.1997;17(2):67-72.
Silberstein SD, Saper JR, Freitag FG. Migraine diagnosis and treatment. In: Silberstein SD, Lipton RB, Dalessio DE, eds. Wolff’s Headache and Other Head Pain. 7th ed. Oxford, England: Oxford University Press. 2001:

17. Acute Migraine Medications
Nonspecific
Simple Analgesics
NSAIDS
Combination analgesics
Opioids
Corticosteroids
Adjunctive therapies
Antiemetics/dopamine antagonists
Specific
Ergotamine/Dihydroergotamine
Triptans

19. Migraine-Specific Treatment Choices
Sumatriptan (Imitrex)
Tablet (25, 50,100mg)
Injection (6mg, 4 mg stat dose)
Single Dose Vial 6mg/0.5cc
Nasal Spray (5, 20mg)
Needleless injection (Sumavel Dose Pro 6mg)
sumatriptan 85 mg and naproxen sodium 500 mg (Treximet)
Zolmitriptan (Zomig)
Tablet (2.5, 5mg)
ZMT (2.5, 5mg)
Nasal Spray 5.0 mg
Naratriptan (Amerge)
Tablet (1, 2.5mg)
Rizatriptan (Maxalt)
Tablet (5, 10mg)
ODT (5, 10mg)
Almotriptan (Axert)
Tablet (6.25,12.5mg)
Frovatriptan (Frova) (Relpax)
Tablet 2.5mg
Eletriptan
Tablet (20,40mg)
DHE-45 (dihydroergotamine mesylate) 4mg/cc injectable
Migranal Nasal Spray 4mg/cc

20. Triptan Pharmacology Tmax (h) Biologic Meta-
t1/2 Before During Activity bolism
Drug (h) Attack Attack (%)
Sumatriptan Mao-A, renal
Zolmitriptan Cyp1A2, Mao-A
Naratriptan Renal, Cyp1A2
Rizatriptan Mao-A, renal
Eletriptan Cyp3A4
Frovatriptan Renal, Cyp1A2
Almotriptan Cyp2d6, 3A4, Mao-A ,renal

21. Migraine Management in the Office
Anticipate the needs of your patients to avoid costly and unpleasant urgent office or emergency department visits
Provide a written or easily referenced plan for urgent care to your patients
Re-assess and modify treatment plans as needed

22. Management Issues at First Visit
Initial therapy
Match treatment needs to attack profile, associated symptoms and level of disability (stratify the care)
Explain recurrence
Back-up therapy
If initial treatment fails
Rescue therapy
Education
Treat early and optimally, lifestyle changes, avoid triggers

23. Escalation of Migraine Pain Optimal Delivery
Fast
Intensity
Slow
Time

24. Rescue therapy Patient has already used oral and usual medication
Injectable treatment used most often
Severe pain and later in the headache
Gastroparesis, nausea or vomiting
Both patient and physician desire rapid relief
Need resources for sicker patients
Need the room

25. Urgent Care Delivery: The Outpatient Clinic Some Things to Consider
Transportation
Drugs may cause sedation or cognitive slowing
Timing
Patient observation
Staffing
Avoid being rushed-establish cut-off times for calls
Severity of Symptoms
Rehydration or electrolyte imbalance may preclude outpatient delivery

26. Outpatient Treatment Protocols
Ask about medication allergy or drug hypersensitivity
Recent medication history (everything)
Be aware of maximum daily dosing to avoid toxicity
Maximum daily dose of sumatriptan is 200 mg orally; 12 mg SQ; 20 mg nasal spray
Maximum daily dose of DHE-45® is 3 mg
Use rational polypharmacy
Respect half-lives of medication and drug interactions

27. Outpatient Treatment Protocols A combination approach
Treatment with injectable anti-nausea medication
Dopamine antagonist if sedation is not an issue
Ondansetron if sedation is to be avoided
Treatment with a migraine specific therapy
Subcutaneous sumatriptan
DHE-45®
Treatment with injectable NSAID (especially if allodynia is present)
Ketorolac IM
Jakubowski M, Levy D, Goor-Areh I. et al. Headache 2005;45:

28. Neuroleptics (D2 receptor antagonists)
Phenothiazines
Prochlorperazine, chlorpromazine, promethazine
Butyrophenones
Droperidol, haloperidol
Metoclopromide
Anti-adrenergic, anticholinergic, antiseritonergic, antihistaminic effects
Sedation, drowsiness, EPS
Prevent EPS (dystonia and akasthesia) by premedicating with an anticholinergic

29. Dopamine Antagonists Medication Delivery and Dose Maximum Daily Dose
Chlorpromazine
12.5 mg-25 mg IM/IV
300 mg
Droperidol
0.625 mg-2.5 mg IV
10mg
Prochlorperazine
5-10 mg IM/IV
40 mg
Promethazine
mg IM/IV (AE w/IM)
100 mg
Metoclopromide
60 mg

30. Guidelines for Initiating Migraine Prevention
Frequency of headache greater than 4-6 per month, disability more than 2-3 days per month or that significantly interferes with quality of life
Use of acute medication more than 2-3 times per week on average or escalating use
Acute medications contraindicated, not tolerated, or ineffective
Presence of uncommon migraine conditions
Hemiplegic or basilar migraine
Migraine with prolonged aura or migrainous infarction
Patient preference
AHS Guidelines for Initiating Migraine Prevention
Key Point: Simple ways to recognize when preventive therapy is medically appropriate.
Source: AAFP/ACP-ASIM Recommendations.

31. Migraine Prevention: Medications
Antidepressants
TCAs, SSRIs, MAOIs
Amitriptyline, nortriptyline
Cardiovascular medications
Propranolol*
Timolol*
Verapamil
Antiepileptic drugs (AEDs)
Divalproex*
Gabapentin
Topiramate*
Zonisamide
Other
NSAIDs
5-HT antagonists
Methysergide*
Other
Riboflavin (B2)
Feverfew
Magnesium (Mg++)
Botulinum toxin
Petasites
ACE inhibitor
Angiotensin II antagonist
Coenzyme Q
Migraine Preventive: Medications
Key Point: Many therapies are currently used for migraine prevention; however, only 5 are approved or seeking approval from the FDA. One of which is no longer available in the US.
This slide shows the range of treatments currently used for migraine prevention. Interestingly, very few of the implemented therapies hold FDA approval for migraine prevention. Those agents that are either FDA-approved or are currently being reviewed by the FDA for migraine prevention are indicated with an asterisk.
Also listed are emerging treatments for migraine prevention. While some of these are drugs others are nutraceuticals that might be of interest to patients that prefer alternative therapies. Butterbur (Petasites), Feverfew, Glucosamine, and Coenzyme Q10 represent alternative therapies that may have efficacy in the treatment of migraine.
TCAs=tricyclic antidepressants; SSRIs=selective serotonin reuptake inhibitors; MAOIs=monoamine oxidase inhibitors; NSAIDs=nonsteroidal anti-inflammatory drugs; ACE=angiotensin-converting enzyme. *Currently holds FDA indication for migraine prevention.

32. Common Comorbidities
Comorbid conditions often found in migraineurs include
Depression
Anxiety
Social phobias
Bipolar disorder
Irritable bowel syndrome
Sleep disorders

33. Migraine Comorbidity May Assist With Selection of Preventive Agent
Anxiety
Bipolar
Depression
Epilepsy
Insomnia
MVP
Raynaud’s
Agent
SSRI/SNRI, AED
AED, SSRI/SNRI
TCA
AED
– b-blocker
Calcium blocker
Comorbidities might influence selection of preventive agents in patients with migraine. This slide lists comorbid conditions and appropriate classes of agents. For example, patients with migraine attacks and a concomitant anxiety disorder might benefit from a selective serotonin reuptake inhibitor or a serotonin-norepinephrine reuptake inhibitor.
Lipton R, Silberstein S. 21st Century Prevention and Management of Migraine Headaches. Clinician. 2001;19:1-26.
AED=antiepileptic (anticonvulsant) drug; MVP=mitral valve prolapse; SSRI=selective serotonin reuptake inhibitor; SNRI=serotonin norepinephrine reuptake inhibitor; TCA=tricyclic antidepressant
Lipton R, Silberstein S. Clinician. 2001;19:1-26.

34. Other Types of Primary Headache
Cluster headache
Occurs in episodes, or “clusters”
Brief, severe pain around 1 eye lasting 15 min to 3 hours
Up to 8 times per day, often waking patient from sleep
Pacing headache
Tension-type headache
Bilateral pressure, vice-like pain of mild to moderate intensity
Rarely accompanied by associated symptoms
It is important to correctly differentiate migraine from other types of headache before determining the optimal treatment.
Cluster headache is the most painful of the primary headaches. It comes on without warning, is unilateral, and is characterized by a rapid increase in pain intensity. It lasts minutes on average, compared with 4-72 hours for migraine, and unlike migraine, is not usually associated with aura, nausea, and vomiting. In contrast to migraine, cluster headache predominates in men (M:F ratio 4:1).
Tension headache is rarely accompanied by nausea, vomiting, photophobia, and phonophobia. It is often accompanied by tightness of the neck and shoulder muscles.
Silberstein SD et al. Wolff’s Headache and Other Head Pain 2001:6-26

35. Treatment of Cluster Headache
Acute therapy
Oxygen 100% for minutes at 8L/miin via tight-fitting mask
Imitrex Injectable 4-6 mg SQ
Short-term prevention
Triptan or ergot at bedtime
Prevention for episodic or chronic
Two preventives with rapid induction
AED e.g. valproic acid or topiramate
Calcium channel blocker e.g. verapamil ( can go up to 480 mg)
Corticosteroids

36. 4.4 Primary headache associated with sexual activity
4.4.1 Preorgasmic headache
A. Dull ache in the head and neck associated with awareness of neck and/or jaw muscle contraction and fulfilling criteria B.
B. Occurs during sexual activity and increases with sexual excitement.
C. Not attributed to another disorder
4.4.2 Orgasmic headache
A. Sudden severe (explosive) headache fulfilling criteria B.
B. Occurs at orgasm.
ICHD-II Cephalalgia 2004; 24 (Supplement 1).

37. Case History 38 year old woman with 25 year h/o episodic headache
Gradual increase in frequency and for the last 6-7 years taking Excedrin Migraine initially 2 tab q 6 h, then q 5h, now q 4 h (10 tabs/day)
During pregnancy switched to Excedrin Tension, now mixes them. May take Excedrin PM to sleep
Rescues with Fiorinal 2 or 3 tab (40/mo). Occasional ER visit
Wakes up with suboccipital headache (3/10) which is constant, becoming unilateral with no predominant side, severe pain (10/10) and nausea about twice/mo for 2 d
Interferes with taking care of her 6 year old and work
Prior neurologist tried sumatriptan, topirimate and amitriptyline

38. Take 2 tablets every 4 hours until you are addicted.

39. Syndrome of Medication Overuse Headache (MOH)
Occurs in patients with pre-existing migraine/pain
Waking with early morning headache
Pattern of headaches and overuse of analgesics in predictable and escalating frequency
Prevention: limit frequency and dose of meds
Treatment: refractory to otherwise appropriate therapy
withdrawal therapy
restriction of monthly doses for acute treatment
Medication overuse and subsequent medication-overuse headache (MOH), also known as rebound headache, is a growing problem. MOH occurs among patients with pre-existing migraine headaches or pain.
MOH consists of a pattern of headaches and overuse of analgesics.
Withdrawal therapy is the only treatment for MOH and restriction of monthly doses is required for successful prevention.
Diener HC, Limmroth V. Medication-overuse headache: a worldwide problem. Lancet Neurol. 2004;3:
Maizels M. The patient with daily headaches. Am Fam Physician. 2004;70:

40. Medications With Risk of MOH or Rebound HA
High
Moderate to Low
Acetaminophen, aspirin, caffeine
Butalbital-containing combinations
Short-acting opioids
Short-acting NSAIDs
Decongestants
Dihydroergotamine mesylate
Long-acting NSAIDs
Simple analgesics
Long-acting opioids
Triptans
Medications with a high risk of medication-overuse headache (MOH) or rebound headache include acetaminophen, aspirin, caffeine, butalbital-containing combinations, and short-acting opioids.
Triptan overuse headache is not encountered with great frequency in clinical practice.
At this time, however, it appears that all triptans should be considered moderate to low inducers of MOH or rebound headache. It remains to be seen whether triptans with longer half-lives distinguish themselves from those with shorter half-lives with regard to MOH.
Smith TR, Stoneman J. Medication overuse headache from antimigraine therapy:
clinical features, pathogenesis and management. Drugs. 2004;64:
Adapted from Smith TR et al. Drugs. 2004;64:

41. Principles of Medication Overuse Headache (MOH) Therapy
Taper medications most likely to cause MOH/rebound
Substitute acute medications that are less likely to cause MOH/rebound
Bridging program during withdrawal
parenteral dihydroergotamine mesylate
low-dose tizanidine with long-acting NSAIDs
daily doses of a triptan for up to 10 days
short course of steroids, long-acting NSAIDs
Preventive Medication
Cautions:
opiate and barbiturate abstinence syndromes
increasing headache during withdrawal period
Medications most likely to cause medication-overuse headache (MOH) should be tapered, and acute medications that do not cause this condition should be used as substitutes. Synergistic combination therapy should also be considered.
The treating physician should be watchful for opiate and barbiturate abstinence syndromes and increasing headache, which can occur during the withdrawal period.
Maizels M. The patient with daily headaches. Am Fam Physician. 2004;70:
Maizels M. Am Fam Physician. 2004;70:

42. Menstrual Migraine Frequency35
Migraine in women (n=55) 30
No. of attacks 25 20 15 10
Women who experience migraines are more likely to have migraine headaches at the time of menses than at other times during the menstrual cycle.
Most women experience these headaches just before or with menstruation.
Silberstein SD, Lipton RB, Goadsby PJ. Headache in Clinical Practice. 2nd ed. London, England: Martin Dunitz Ltd.; 2002. 5 34 29 24 19 14 9 4 2 7 12 17 22 27 32
Day of cycle
Day 1 = first day of bleeding
Used with permission from Headache in Clinical Practice. Copyright © 1998, 2002 Martin Dunitz Ltd. 76

43. Menstrually Related Migraine (MRM) Occurs Days -2 to +3
Approximately 60% of women who experience migraine relate the frequency of their attacks to the menstrual cycle
Pure menstrual migraine occurs from days -2 to +3 of menstruation in at least 2 out of 3 menstrual cycles
Menstrually related migraine always occurs
on days -2 to +3 in at least 2 out of 3 menstrual cycles, as well as other times of the cycle
The occurrence of migraine headaches is strongly influenced by the hormonal fluctuations of the female reproductive cycle. Menstrual migraine occurs immediately before, during, or at the end of the menstrual flow.
Pure menstrual migraine occurs during days -2 to +3.
Menstrually related migraine occurs on days -2 to +3, as well as other times of the cycle.
Allais G, Benedetto C. Update on menstrual migraine: from clinical aspects to therapeutical strategies. Neurol Sci. 2004;25(suppl 3):S229-S231.
Allais G, Benedetto C. Neurol Sci. 2004;25 (suppl 3):S229-S231.

44. Hormone Levels During Menstrual Cycle
HORMONAL FLUCTUATIONS DURING THE MENSTRUAL CYCLE
Follicular phase
Luteal phase
Endocrine
cycle
Ovulation P E2 LH
FSH
Adapted from Silberstein SD, Lipton RB, Goadsby PJ. Headache in Clinical Practice. 2nd Ed. New York, NY: Martin Dunitz; 2002:102

45. Case Study: Menstrual Migraine Over Time
23 year old nulliparous female
History of true menstrual migraine without aura since menarche
Headaches changes 6 months ago with administration of oral contraceptives
Now migraines present with aura and weakness never experienced before
Concerns with oral contraceptives or alternate etiology

46. Migraine as a Risk Factor for Stroke (Migraine Coexistent with Stroke)
Stroke risk in young (less than 45 years of age) female population is generally very low
estimated to be between 5 and 10 per 100,000 woman-years
However, there is increased stroke risk (odds ratio) in women migraineurs under age 45:
Odds Ratio (OR)
Migraine
Migraine with aura
Migraine plus OC’s
Migraine plus OC’s plus smoking
• Relative risk seems high, but absolute risk in migraineurs is low:
17 to 19 in 100,000
There is no evidence that migraine is a risk factor for stroke in women over age 45
MacGregor EA, de Lignieres B. Cephalalgia 2000; 20:
IHS Task Force on Combined OC and HRT. Bousser MG et al. Cephalalgia 2000; 20:

47. New persistent headache New onset of migraine with aura
Migraine-related Symptoms That May Require Further Evaluation and/or Cessation of Oral Contraceptives
New persistent headache
New onset of migraine with aura
Increased headache frequency or intensity
Unusual or prolonged aura symptoms
IHS Task Force on Combined OC and HRT. Bousser MG et al. Cephalalgia 2000; 20:

48. Summary of Medication Efficacy for Urgent Care

49. Percent Patients with Pain Relief82 78 77 70 67 65 60 58 45 43 % 37 32
Weighted averages of percentages of pain relief for all medications for which there were at least 2 randomized trials with drug used as a single agents. Adapted from Fig. 1 in: Kelley NE and Tepper DE. Rescue Therapy for Acute Migraine, Part 3: Opioids, NSAIDs, Steroids, and Post-Discharge Medications. Headache 2012;52:

50. Percent Patients with Pain Freedom53 53 40 35 41 36 30 % 21 22 14
Weighted averages of percentages of pain free for all medications for which there were at least 2 randomized trials with drug used as a single agents. Adapted from Fig. 2 in: Kelley NE and Tepper DE. Rescue Therapy for Acute Migraine, Part 3: Opioids, NSAIDs, Steroids, and Post-Discharge Medications. Headache 2012;52:

51. Summary
Prochlorperazine and metoclopromide are the most frequently studied medications used in the ED with efficacy superior to placebo
Triptans and DHE are equivalent to the dopamine antagonists for migraine pain relief
Opioids are superior to placebo in efficacy
Steroid use can decrease headache recurrence after discharge.

52. Conclusions
Based on weighted averages of percentage pain relief for medications studied in at least 2 randomized single agent trials:
Recommend combination of:
Droperidol or proclorperazine IV (77-82% pain relief)
Sumatriptan 6 mg SQ or DHE IV (67-78% pain relief)
Ketorolac 30 mg IV or dexamethasone 6 mg IV (69-78% pain relief)
Based on weighted averages of percentage pain free for medications studied in at least two randomized trials with drugs used as single agents:
Proclorperazine IV or chlorpromazine IV (53% pain free)
Meperidine IM, sumatriptan SQ or magnesium IV (30-36% pain free)
IV is the preferred route of administration and recurrence many be decreased by the addition of dexamethasone

53. Thank you!