Migraine Headache — Discharge Medications — Clinical Pathway: Inpatient

Migraine Headache Clinical Pathway — Inpatient

Discharge Medications

If patient responded to the medications below, consider the following Bridge Treatment:

Ibuprofen/Ketorolac
  • Ibuprofen 10 mg/kg PO, max 800 mg/dose, q 6 hours PRN; x3 days, then max 3 doses/day for 3 days/week
  • Side effects: stomach upset
Metoclopramide
  • Provide a prescription for 2 doses of Metoclopramide for home use.
    • 1st dose may be given 6 hours following the ED dose
    • Additional dose may be given in 6 hours after the first does if the headache continues
  • Dose 0.2 mg/kg PO
  • Max: 10mg
  • SE: Sedation, restlessness, rare dystonic reaction (treat with diphenhydramine)
Valproic Acid
  • Discuss home dosing with Neurology
    • 15 mg/kg, max 500mg/dose at bedtime, 2-week course
  • Side effects: nausea, drowsiness, dizziness, vomiting, decreased appetite, tremors
  • Uncommon serious side effects: liver dysfunction, hepatic failure, pancreatitis, teratogenicity, ovarian cysts
Methylprednisolone
  • < 12kg — Discharge with Prednisone 2mg/kg/day with rapid taper over 5-6 days
  • ≥ 12kg use Medrol dose pack (4mg tablets)
    • Take 6 tabs on day 1, 5 tabs on day 2, 4 tabs on day 3, 3 tabs on day 4, 2 tabs on day 5, and 1 tab on day 6.
  • Do not give simultaneous NSAIDs while on steroids
  • Side effects: increased appetite, stomach upset, irritability, mood changes, insomnia
Magnesium Formulations:
  • Magnesium Oxide — Poorly absorbed so may cause more diarrhea with initiation. Most formulations are available in pharmacies as 20mEq/tab.
  • MG Plus Protein (Magnesium Amino Acid Chelate) — Well absorbed, 11mEq/tab, tabs can be crushed. May need to be ordered by pharmacist or online.
Dose:
  • < 50kg: approximate doses, will need to adapt slightly for pill size
    • Week 1 — 0.25 mEq/kg/day once daily
    • Week 2 — 0.5 mEq/kg/day divided twice daily
    • Week 3 and continue — 0.75 mEq/kg/day divided three times daily
  • ≥ 50kg:
    • Week 1 — 10mEq once daily
    • Week 2 — 10mEq twice daily
    • Week 3 and continue — 10mEq three times daily
    • Note: 10 mEq magnesium = 120 milligrams elemental magnesium = ~1 tab of MG Plus Protein or ~1/2 tab of Magnesium Oxide
    • Side effects: diarrhea, stomach upset. To minimize this increase slowly and take with food
DHE If patient received 16 or fewer doses of IV DHE
  • Consider discharge with Migranal (nasal DHE) bridge
  • 1 spray in each nostril every 8 hrs x 4 doses (0.5mg each spray, so total of 1mg every 4 hours)
  • * Note: Migranal is very expensive, and often not covered by insurance
Side effects:
  • Nausea — Pre-medicate with Ondansetron and/or Metoclopramide oral (whichever was helpful inpatient)
  • Bad taste — Instruct patient to spray into nose with shallow inhalation, nose down toward toes
  • Patients should not combine triptan medication and DHE within 24 hours
Nerve Block No specific discharge treatment indicated. May be repeated outpatient in the future if benefits are long-lasting.

Vitamin Supplementation

Vitamin D
  • If level < 30 ng/mL supplement with Cholecalciferol (D3) 50,000 international units weekly x 8 weeks then 2000 international units daily
  • If level > 30 ng/mL ensure at least 1000 international units daily through diet or supplement with cholecalciferol (D3)
Vitamin B2 (riboflavin)
  • If level < 10 nmol/L supplement with 200 mg BID

Headache Preventive Medications

Discuss with Neurology team whether to start or change preventive medications.