Inpatient Pathway for the Evaluation/Treatment of the Patient with Migraine Headache
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  • Sufficient Clinical Improvement
    • Decreases in Pain Score by 1 Point
    • Patient Reports Subjective Improvement
  • Reassess Every 8-12 Hours to Ensure Continued Improvement
  • Consider Adjunctive Pain Management Interventions
    • Patient Education
    • Child Life
    • Social Work
    • Psychology/Psychiatry

Pathway assumes patient has received Ketorolac, Metoclopramide, and Valproic Acid at this point.

If additional medications administered in ED, advance along pathway as clinically indicated.

Modify protocol as needed dependent on success/failure/side effects of past medications.

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Sufficient Improvement
Start Diphenhydramine
Continue Ketorolac
Metoclopramide
Valproic Acid
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Insufficient Improvement
Stop Valproic Acid
Start Diphenhydramine
Methylprednisolone
Continue Ketorolac
Metoclopramide
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Reassess 30-60 Minutes Following Methylprednisolone
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Sufficient Improvement
Insufficient Improvement
Stop Ketorolac
Start Ranitidine
Continue Metoclopramide
Diphenhydramine
Methylprednisone
Stop Methylprednisolone
Start Magnesium Sulfate
Continue Ketorolac
Metoclopramide
Diphenhydramine
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Reassess 30-60 Minutes after Magnesium Sulfate
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Sufficient Improvement
Insufficient Improvement
Continue Magnesium Sulfate
Ketorolac
Metoclopramide
Diphenhydramine
Stop Magnesium Sulfate
Start DHE
Continue Ketorolac
Metoclopramide
Diphenhydramine
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Sufficient Improvement
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Continue DHE
Ketorolac
Metoclopramide
Diphenhydramine
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Posted: April 2015
Revised: May 2017, March 2018
Authors: C. Szperka, MD; P. Betts, PharmD; K. Dorland, RN; D. Karvounides, PhD; C. Malavolta, CRNP;
N. Lin, MD; J. Lavelle, MD; C. Salas-Humara, MD