IM Migraine Relief: 5 Questions for Primary Care

Peter McAllister, MD, is Medical Director at the New England Institute for Neurology and Headache and Chief Medical Officer for the New England Institute for Clinical Research and Ki Clinical Research, all located in Stamford, Conn.

When a headache patient arrives for follow-up with a full-blown migraine in progress, what can you do to help? Referral to the emergency department is rarely ideal and calling a neurologist colleague for a same-day appointment most likely won't work.

In our practice we keep 5 injectable medications on hand -- they're inexpensive, easily stored, and can be invaluable for your next patient in distress. Following are 5 questions on what could turn into simple injectable solutions.

Q1: In a recent study done in the emergency department at New York University, which of the following was felt to be the most effective abortive agent for acute migraine?

A. Metoclopramide (Reglan)

B. Ketorlac (Toradol)

C. Lidocaine (Xylocaine)

D. Ondansetron (Zofran)

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Answer: A. Metoclopramide. Administered as an intramuscular injection in the office, 10 mg of metoclopramide is usually effective and can be repeated in 30 minutes if necessary. 

Q2: Combining IM ketorolac with metoclopramide is often sufficient to end most migraines. The recommended dose of ketorolac is:A. 30 mg

B. 40 mg

C. 50 mg

D. 60 mg

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Answer: D. 60 mg.  Keterolac 60 mg IM should be enough to end a migraine when combined with 10 mg metoclopramide. Since it is a potent NSAID, use with caution (and consider halving the dose) in patients with impaired renal function.

Q3: Dexamethasone administered IM has been found effective as a migraine abortive agent.

A. True

B. False

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Answer: B. False.  A dose of 10 mg dexamethasone IM won’t alleviate the migraine immediately; but the powerful anti-inflammatory effects will kick in over several hours and “put out the fire” of a centrally sensitized long-duration migraine. 

Q4. Ondansetron is highly effective for the nausea component of migraine and is administered IM at the standard dose of:

A. 2-4 mg

B. 4-8 mg

C. 6-10 mg

D. Another dose

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Answer: B. 4-8 mg IM is the standard dose of ondansetron administered to quell migraine-associated nausea. Ondansetron may be combined with metoclopramide or used alone in those with sensitivity to Reglan.

Q5: If none of the foregoing, alone or in combination, prove effective, a subcutaneous approach is worth trying, using which of the following?

A. Bupivacaine

B. Lidocaine

C. OnabotulinumtoxinA

D. Lidocaine/prilocaine

E. Ropivacaine

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Answer: B. Lidocaine. Lidocaine can be used subcutaneously to block the occipital nerve. Generally, 1-2% lidocaine is drawn up into a 3-mL syringe, which is topped off with a 27 or 30 gauge needle (note: a 50/50 mix of lidocaine and 0.5% bupivacaine may also be used).

Then get behind the patient and locate a point one third of the way from the inion to the mastoid (along the nuchal line) and slowly infiltrate the subcutaneous space, fanning the needle, 1.5 cc per side. The patient may feel numb in the injected area for a few hours, but there are no other side effects.

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This quiz is based on an earlier article written by Dr McAllister that you can read here: Take a Shot at Headache: 5 Useful In-officeInjectables

For additional reading on headache and migraine, return to the Patient Care Online Headache and Migraine topic resource center.