Rescue Treatment for Migraine Headache in Emergency Department Part 2: Role of Antiepileptic, Magnesium, Corticosteroids, and Discharge Care

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Kiratikorn Vongvaivanich, MD


Migraine is a common chronic neurological disorder, associated with a high disease-related disability and may lead migraineurs to the Emergency Department (ED). The efficacy of valproate, magnesium sulfate, corticosteroids as the rescue treatment for migraine headaches in ED has been reviewed. Nearly half of patients with migraine headaches discharged from the ED had received neither a specific diagnosis nor appropriate patient education. Hence, discharge planning and a migraine education program at the ED was also highlighted in this article.


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Vongvaivanich K. Rescue Treatment for Migraine Headache in Emergency Department Part 2: Role of Antiepileptic, Magnesium, Corticosteroids, and Discharge Care. BKK Med J [Internet]. 2014 Sep. 20 [cited 2023 Nov. 30];8(1):79. Available from:
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1. World Health Organization. Atlas of headache disorders and resources in the world 2011 / a collaborative project of World Health Organization and Lifting the Burden. Geneva: World Health Organisation, 2011.
2. Blumenfeld AM, Varon SF, Wilcox TK, et al. Disability, HRQoL and resource use among chronic and episodic migraineurs: results from the International Burden of Migraine Study (IBMS). Cephalalgia 2011;31:301-15.
3. Stovner L, Hagen K, Jensen R, et al. The global burden of headache: a documentation of headache prevalence and disability worldwide. Cephalalgia 2007;27:193-210.
4. Vos T, Flaxman AD, Naghavi M, et al. Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and njuries 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012;380:2163-96.
5. Steiner TJ, Stovner LJ, Birbeck GL. Migraine: the seventh disabler. Cephalalgia 2013;33:289-90.
6. Lipton RB, Bigal M, Diamond M. Migraine prevalence, disease burden and the need for preventive therapy. Neurology 2007;68:343-9.
7. Smitherman TA, Burch R, Sheikh H, Loder E. The prevalence, impact, and treatment of migraine and severe headaches in the United States: a review of statistics from national surveillance studies. Headache 2013;53:427-36.
8. Goldstein JN, Camargo CA Jr, Pelletier AJ, et al. Headache in United States emergency departments: demographics, work-up and frequency of pathological diagnoses. Cephalalgia 2006;26:684-90.
9. Cevoli S, D’Amico D, Martelletti P, et al. Underdiagnosis and undertreatment of migraine in Italy: a survey of patients attending for the first time 10 headache centres. Cephalalgia 2009;29:1285-93.
10. Gupta MX, Silberstein SD, Young WB, et al. Less is not more: underutilization of headache medications in a university hospital emergency department. Headache 2007;47:1125-33.
11. Diamond M, Cady R. Initiating and optimizing acute therapy for migraine: the role of patient-centered stratified care. Am J Med 2005;118:S18-S27.
12. Minen MT, Tanev K, Friedman BW. Evaluation and treatment of migraine in the emergency department: a review. Headache 2014;54:1131-45.
13. Colman I, Rothney A, Wright SC, et al. Use of narcotic analgesics in the emergency department treatment of migraine headache. Neurology 2004;62:1695-700.
14. Tepper SJ. Opioids should not be used in migraine. Headache 2012;52:30-4.
15. Friedman BW, West J, Vinson DR, et al. Current manage-ment of migraine in US emergency departments: An analysis of the National Hospital Ambulatory Medical Care Survey. Cephalalgia 2014.
16. 16. Vinson DR, Hurtado TR, Vandenberg JT, et al. Variations among emergency departments in the treatment of benign headache. Ann Emerg Med 2003;41:90-7.
17. Silberstein SD. Practice Parameter--Evidence-based guidelines for migraine headache (an evidence-based review): Report of the Quality Standards Subcommittee of the American Academy of Neurology for the United States Headache Consortium. Neurology 2000;55:754-62.
18. Vongvaivanich K. Rescue Treatment for Migraine Headache in Emergency Department Part 1: Diagnosis, General Management, and Role of Dopamine Antagonists and NSAIDs. Bangkok Med J 2014;7:86-93.
19. Linde M, Mulleners WM, Chronicle EP, et al. Valproate (valproic acid or sodium valproate or a combination of the two) for the prophylaxis of episodic migraine in adults. Cochrane Database Syst Rev 2013;6:CD010611.
20. Klapper JA. Divalproex sodium in migraine prophylaxis:A dose-controlled study. Cephalalgia 1997;17:103-8.
21. Shahien R, Saleh SA, Bowirrat A. Intravenous sodium valproate aborts migraine headaches rapidly. Acta Neurol Scand 2011;123:257-65.
22. Robertson CE, Black DF, Swanson JW. Management of migraine headache in the emergency department. Semin Neurol 2010;30:201-11.
23. Mathew NT, Kailasam J, Meadors L, et al. Intravenous valproate sodium (depacon) aborts migraine rapidly: a preliminary report. Headache 2000;40:720-3.
24. Stillman MJ, Zajac D, Rybicki LA. Treatment of primary headache disorders with intravenous valproate: initial outpatient experience. Headache 2004;44:65-9.
25. Waberzinek G, Markova J, Mastik J. Safety and efficacy of intravenous sodium valproate in the treatment of acute migraine. Neuro Endocrinol Lett 2007;28:59-64.
26. Leniger T, Pageler L, Stude P, et al. Comparison of intra venous valproate with intravenous lysine-acetylsalicylic acid in acute migraine attacks. Headache 2005;45:42-6.
27. Edwards KR, Norton J, Behnke M. Comparison of intra venous valproate versus intramuscular dihydroergotamine and metoclopramide for acute treatment of migraine headache. Headache 2001;41:976-80.
28. Hering R, Steiner TJ. Sodium valproate for acute migraine attacks. Cephalalgia 1994;14:305-6.
29. Cutrer FM, Moskowitz MA. The actions of valproate and neurosteroids in a model of trigeminal pain. Headache 1996;36:265.
30. Cutrer FM, Limmroth V, Moskowitz MA. Possible mech-anisms of valproate in migraine prophylaxis. Cephalalgia 1997;17:93-100.
31. Friedman BW, Garber L, Yoon A, et al. Randomized trial of IV valproate vs metoclopramide vs ketorolac for acute migraine. Neurology 2014;82:976-83.
32. Bakhshayesh B, Seyed Saadat SM, Rezania K, et al. A randomized open-label study of sodium valproate vs sumatriptan and metoclopramide for prolonged migraine headache. Am J Emerg Med 2013;31:540-4.
33. Tanen DA, Miller S, French T, et al. Intravenous sodium valproate versus prochlorperazine for the emergency department treatment of acute migraine headaches: a prospective, randomized, double-blind trial. Ann Emerg Med 2003;41:847-53.
34. Orr SL, Aube M, Becker WJ, et al. Canadian Headache Society systematic review and recommendations on the treatment of migraine pain in emergency settings. Cephalalgia 2014.
35. Rude RK, Singer FR. Magnesium deficiency and excess. Annu Rev Med 1981;32:245-59.
36. Ramadan NM, Halvorson H, VandeLinde A, et al. Low brain magnesium in migraine. Headache 1989;29:416-9.
37. Ambrosini A, Schoenen J. The electrophysiology of migraine. Curr Opin Neurol 2003;16:327-31.
38. Welch KM, Ramadan NM. Mitochondria, magnesium and migraine. J Neurol Sci 1995;134:9-14.
39. Mori H, Masaki H, Yamakura T, et al. Identification by mutagenesis of a Mg(2+)-block site of the NMDA receptor channel. Nature 1992;358:673-5.
40. Mauskop A, Varughese J. Why all migraine patients should be treated with magnesium. J Neural Transm 2012;119:575-9.
41. Tepper SJ, Rapoport A, Sheftell F. The pathophysiology of migraine. Neurologist 2001;7:279-86.
42. Strong AJ, Fabricius M, Boutelle MG, et al. Spreading and synchronous depressions of cortical activity in acutely injured human brain. Stroke 2002;33:2738-43.
43. Rozen TD. Aborting a prolonged migrainous aura with intravenous prochlorperazine and magnesium sulfate. Headache 2003;43:901-3.
44. Taylor FR. Nutraceuticals and headache: the biological basis. Headache 2011;51:484-501.
45. Mauskop A, Altura BT, Cracco RQ, Altura BM. Deficiency in serum ionized magnesium but not total magnesium in patients with migraines. Possible role of ICa2+/IMg2+ratio. Headache 1993;33:135-8.
46. Mauskop A, Altura BT, Altura BM. Serum ionized magnesium levels and serum ionized calcium/ionized magnesium ratios in women with menstrual migraine. Headache 2002;42:242-8.
47. Mauskop A, Altura BT, Cracco RQ, Altura BM. Intravenous magnesium sulfate rapidly alleviates headaches of various types. Headache 1996;36:154-60.
48. Demirkaya S, Vural O, Dora B, Topcuoglu MA. Efficacy of intravenous magnesium sulfate in the treatment of acute migraine attacks. Headache 2001;41:171-7.
49. Corbo J, Esses D, Bijur PE, Iannacconne R, Gallagher EJ. Randomized clinical trial of intravenous magnesium sulfate as an adjunctive medication for emergency department treatment of migraine headache. Ann Emerg Med 2001;38:621-7.
50. Bigal ME, Bordini CA, Tepper SJ, et al. Intravenous magnesium sulphate in the acute treatment of migraine without aura and migraine with aura. A randomized, double-blind, placebo-controlled study. Cephalalgia 2002; 22:345-53.
51. Cete Y, Dora B, Ertan C, et al. A randomized prospective placebo-controlled study of intravenous magnesium sulphate vs. metoclopramide in the management of acute migraine attacks in the Emergency Department. Cephalalgia 2005;25:199-204.
52. Ginder S, Oatman B, Pollack M. A prospective study of i.v. magnesium and i.v. prochlorperazine in the treatment of headaches. J Emerg Med 2000;18:311-5.
53. Kelley NE, Tepper DE. Rescue therapy for acute migraine, part 1: triptans, dihydroergotamine, and magnesium. Headache 2012;52:114-28.
54. Choi H, Parmar N. The use of intravenous magnesiumn sulphate for acute migraine: meta-analysis of randomized controlled trials. Eur J Emerg Med 2014;21:2-9.
55. Gilmore B, Michael M. Treatment of acute migraine headache. Am Fam Physician 2011;83:271-80.
56. Rozen TD. Migraine Headache: Immunosuppressant Therapy. Curr Treat Options Neurol 2002;4:395-401.
57. Krymchantowski AV, Moreira PF. Out-patient detoxifi-cation in chronic migraine: comparison of strategies. Cephalalgia 2003;23:982-93.
58. Colman I, Friedman BW, Brown MD, et al. Parenteral dexamethasone for acute severe migraine headache: meta-analysis of randomised controlled trials for preventing recurrence. BMJ 2008;336:1359-61.
59. Friedman BW, Solorzano C, Esses D, et al. Treating head-ache recurrence after emergency department discharge: a randomized controlled trial of naproxen versus suma-triptan. Ann Emerg Med 2010;56:7-17.
60. Ducharme J, Beveridge RC, Lee JS, et al. Emergency management of migraine: is the headache really over? Acad Emerg Med 1998;5:899-905.
61. Friedman BW, Greenwald P, Bania TC, et al. Randomized trial of IV dexamethasone for acute migraine in the emergency department. Neurology 2007;69:2038-44.
62. Goadsby PJ, Lipton RB, Ferrari MD. Migraine-current understanding and treatment. N Engl J Med 2002;346: 257-70.
63. Moskowitz MA. Neurogenic inflammation in the pathophysiology and treatment of migraine. Neurology 1993;43:S16-S20.
64. Burstein R, Collins B, Jakubowski M. Defeating migraine pain with triptans: a race against the developing allodynia. Ann Neurol 2004;55:19-26.
65. Jakubowski M, Levy D, Kainz V, et al. Sensitization of central trigeminovascular neurons: blockade by intrave- nous naproxen infusion. Neuroscience 2007;148:573-83.
66. Innes GD, Macphail I, Dillon EC, et al. Dexamethasone prevents relapse after emergency department treatment of acute migraine: a randomized clinical trial. CJEM 1999; 1:26-33.
67. Huang Y, Cai X, Song X, et al. Steroids for preventing recurrence of acute severe migraine headaches: a meta-analysis. Eur J Neurol 2013;20:1184-90.
68. Sahai-Srivastava S, Desai P, Zheng L. Analysis of headache management in a busy emergency room in the United States. Headache 2008;48:931-8.
69. Friedman D, Feldon S, Holloway R, et al. Utilization, diagnosis, treatment and cost of migraine treatment in the emergency department. Headache 2009;49:1163-73.
70. Smith TR, Nicholson RA, Banks JW. Migraine education improves quality of life in a primary care setting. Headache 2010;50:600-12.
71. Matchar DB, Harpole L, Samsa GP, et al. The Headache Management Trial: A Randomized Study of Coordinated Care. Headache 2008;48:1294-310.
72. Rothrock JF, Parada VA, Sims C, et al. The impact of intensive patient education on clinical outcome in a clinic-based migraine population. Headache 2006;46:726-31.
73. Buse DC, Silberstein SD, Manack AN, Papapetropoulos S, Lipton RB. Psychiatric comorbidities of episodic and chronic migraine. J Neurol 2013;260:1960-9.
74. Antonaci F, Nappi G, Galli F, et al. Migraine and psychi-atric comorbidity: a review of clinical findings. J Head- ache Pain 2011;12:115-25.
75. Victor TW, Hu X, Campbell J, et al. Association between migraine, anxiety and depression. Cephalalgia 2010;30: 567-75.
76. Baskin SM, Smitherman TA. Migraine and psychiatric disorders: comorbidities, mechanisms, and clinical applications. Neurol Sci 2009;30:S61-S65.
77. Maizels M, Smitherman TA, Penzien DB. A review of screening tools for psychiatric comorbidity in headache patients. Headache 2006;46:S98-109.
78. Rist PM, Schurks M, Buring JE, et al. Migraine, headache, and the risk of depression: Prospective cohort study. Cephalalgia 2013;33:1017-25.
79. Ashina S, Serrano D, Lipton RB, et al. Depression and risk of transformation of episodic to chronic migraine. J Headache Pain 2012;13:615-24.
80. Bruti G, Magnotti MC, Iannetti G. Migraine and depression: bidirectional co-morbidities? Neurol Sci 2012;33:107-9.
81. Breslau N, Schultz LR, Stewart WF, et al. Headache and major depression: is the association specific to migraine? Neurology 2000;54:308-13.
82. Friedman BW, Bijur PE, Lipton RB. Standardizing emergency department-based migraine research: an analysis of commonly used clinical trial outcome measures. Acad Emerg Med 2010;17:72-9.
83. Kelley NE, Tepper DE. Rescue therapy for acute migraine, part 3: opioids, NSAIDs, steroids, and post- discharge medications. Headache 2012;52:467-82.
84. Friedman BW, Serrano D, Reed M, et al. Use of the emergency department for severe headache. A population- based study. Headache 2009;49:21-30.