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Template:Non-specific headache treatment
From WikEM
Non-specific Headache
Treat specific headache type, if known
- 1st line: prochlorperazine (compazine) 10 mg IV (+/- diphenhydramine 25-50 mg IV) + 1 L normal saline IV bolus
- Place prochlorperazine in IV bag to reduce chances of side effects from rapid administration
- Alternative metoclopramide 10 mg IV[1] (diphenhydramine addition shows no clinical benifit[2])
- Acetaminophen IV or PO, 325-1000 mg
- Ketorolac 30 mg IV
- Lower doses are shown to be just as effective[3]
- Consider dexamethasone 10 mg IV single dose to prevent recurrence 48-72 hrs post-ED discharge, if history of recurrent headaches[4]
- Avoid opioid medications if possible
Other 2nd and 3rd Line Medications
- Magnesium 1 g IV over 30-60 minutes, low side effect profile, in treatment of acute migraine attacks[5]
- Valproate sodium 500-1000 mg IV in 50 mL of NS over 20 minutes (alternatively 10 mg/kg IV, pediatrics, max 500 mg)[6]
- Droperidol IV/IM 1.25-2.75 mg, plus or minus diphenhydramine for extrapyramidal symptoms[7]
- Perform EKG monitoring for patients at risk of QTc prolongation
- Do not give to patients who take already multiple QT prolonging drugs
- Consider haloperidol IV 5 mg in IVF bolus with diphenhydramine to prevent need for rescue medications[8]
- Consider 5-10 mg PO olanzapine (Zyprexa, Zydis) for prochlorperazine allergy[9][10]
- While less extrapyramidal symptoms than typical antipsychotics, beware QT prolongation
- Particularly useful in psych patients with mania, BPD, psychosis
- IV olanzapine may be as safe or safer than IM, with faster onset[11]
- Ketamine IM/IV at subdissociative dosages, with risk stratification for potential ICP increase, though now widely considered a myth[12]
- Cervical spine injection with IM injection of 1.5 mL of 0.5% bupivacaine (plus or minus methylprednisolone acetate) bilaterally to the sixth or seventh spinous process[13]
- Severe, intractable status migrainosus may benefit from off-label IV propofol[14][15][16]
- Requires procedural sedation monitoring and possible IV fluid resuscitation, respiratory decompensation intervention
- Propofol 0.5 mg/kg bolus, then 0.25 mg/kg every 10 minutes for 1 hour
- Less aggressive regimens include propofol 10 mg q5-10 min to ma of 80 mg[17]
- Consider using 1 mL 2% lidocaine added to every 10 mL of 10 mg/mL concentration propofol
- Average dosage required ~100-125 mg
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