Menu

Medications

What You Need to Know about Migraine in Emergency

, , 18

Some newly published information is aimed to help patients and help professionals understand how migraine is treated in the emergency department (ER/ED).  The Agency for Healthcare Research and Quality in the USA worked with the University of Alberta Evidence-based Practice Center in Canada to review and publish the information that has been gathering over the past few years.

Treating Severe Migraine Headaches in the Emergency Room

This information is aimed to help patients know what to expect, and to help doctors know what treatments have the best science behind them.  Treatment in emergency is unique, with special challenges.

Here are some of the basics of treatment in emergency:

  • You should especially get to emergency if your headache is very severe, if you have new or different symptoms, if you have a stiff neck or fever, or your headache starts very suddenly (especially if you’re over 50).
  • Most (though not all) medications in the ED are given by a shot or through an intravenously (IV).
  • Although pain is usually a major focus of treatment, your doctor may also need to focus on treating nausea and dehydration.

You may be disappointed with the studies’ use of the terms “migraines” and “migraine headaches”, which does tend to confuse the fact that migraine attacks, often serious ones, can come without severe headache.  And to be fair, this is a focus on treating migraine headaches specifically.  But although it’s understandable that the authors want to simplify things and use language people will recognize, I’m afraid the message will be that every migraine attack involves severe headache.

Recommended Treatments

You can use the links below to read through the material more carefully, but here are some of the treatments considered the best by the authors, based on their review of 71 clinical trials.

Of course, the “best treatment” may not be the best for you, depending on your symptoms and medical history.

Some of the most recommended treatments:

  • sumatriptan
  • neuroleptics (such as chlorpromazine or droperidol)
  • NSAIDs (such as diclofenac or ketorolac)
  • antiemetics (in particular metoclopramide)
  • opioids are useful in some instances, but now rarely used because of side effects and risk of overuse.

One more interesting treatment is dexamethasone (Decadron), which is given in order to keep the pain from returning.  It’s usually given along with another treatment, but because of the risk of side effects it’s not usually used unless the patient is at particular risk of an attack returning over the next few days.

There are other medications which may be used, and often they are used in combination (DHE may be effective in combination with other medications).  But generally the medications above have the best evidence behind them – that means fewer side effects and better results – especially relieving pain and intensity of pain.

In spite of the concerns and cautions mentioned above, this should be a useful resource so that you, as a patient, know more about what to expect and what you should discuss with your doctor.  Doctors, this will give you a quick review of the current science of treatment in the ED and ideas of what you need to discuss with your patients.

For patients:  Treating Severe Migraine Headaches in the Emergency Room
For doctors/clinicians:  Comparative Effectiveness Review Summary Guides for Clinicians

Migraine – Botox – And Funny Eyebrows

, , 6

Have you ever wondered why some people who have had Botox (botulinum toxin A) treatment have strange looking eyebrows?

Botox and Mr. Spock Eyebrows

It’s called the Mephisto Sign, or perhaps Mr. Spock Eyebrows.  Basically, one or both eyebrows arch, making the patient look – surprised, all the time.  And they probably are.

This is a possible problem for migraine patients when they receive injections in the forehead.  What happens is, the frontalis muscle of the forehead becomes hyperactive, causing the eyebrows to arch.  You can see an example of the Mephisto sign from Botox here.

Fortunately, even if this happens it can usually be fixed.  Another injection to the lateral-most point (the outer part) of the frontalis muscles should fix the problem, although you may still be waiting a few days.

Although a pretty minor problem compared to chronic migraine pain, the Mephisto sign can be a pretty annoying problem, as well as a dead giveaway that someone has had Botox treatment, for whatever reason.

It’s just another reminder that you need to make sure you’re going to a specialist experienced in Botox (or Dysport or Xeomin) migraine treatment.  Make sure they keep a careful record of exactly where you have been injected each time.  And do return to them if you have any problems with your treatment, including eyebrows that won’t behave.

Here’s some more information about How to be Safe with Botox (10 tips).

Also see A proposal to prevent the “mephisto sign” side effect of botulinum toxin type a injection in chronic migraine.

Medication-Overuse Headache and the Brain (new study)

, 11

It has been estimated that half of the patients with chronic headache types have medication-overuse headache.  If you’re taking abortive medication for more than 10 days each month, you may have medication-overuse headache (commonly called rebound headache).

Medication-overuse Headache - what are the dangers?

MOH could be a result of abortive medications such as triptans, paracetamol / acetaminophen, ibuprofen, and many others.  The good news is that most patients seem to improve once they stop taking the medication.  They also tend to respond better to preventative medications.

The bad news is that some patients do not improve – a significant number.  Has the medication overuse done permanent damage to the brain?

A study in Switzerland, published last month, investigated grey matter changes in the brain to see if there was a difference among patients who did improve and who didn’t.

Changes in grey matter related to chronic pain are well known.  But could these changes predict how well a patient will respond to treatment?

These researchers believe so.  The evidence demonstrated that there were indeed differences between patients who improved and patients who did not.  A lot of the difference could be seen in the orbitofrontal cortex area of the brain.

The orbitofrontal cortex is one of the least-understood areas of the brain, but it does seem to relate to decision-making, mood, and social interactions.

This study is another reminder of how important it is to get proper ongoing treatment.  It also shows again that every patient is different.  It may give us clues about how well certain patients will respond to certain treatments, and how headache conditions and other chronic pain conditions impact the brain physically.

References:

New Migraine Drugs: What About CGRP?

, , 3

What about CGRP?

CGRP – calcitonin gene-related peptide neurotransmitter.  Sends messages in your body related to PAIN.

Is CGRP blocking the new frontier of migraine medicine?

Actually, CGRP blocking could be one reason why triptan drugs work.  But some researchers believe that better drugs targetting CGRP could better block migraine symptoms with fewer side effects.  Researchers want to use antibodies to stop CGRP in its tracks.

Who’s working on these drugs?

  • Labrys Biologics:  A drug called LBR-101
  • Arteaus Therapeutics:  A drug called LY2951742
  • Amgen:  A drug called AMG 334
  • Alder Biopharmaceuticals:  A drug called ALD 403

For more on CGRP and these upcoming drugs, read The Secret of CGRP and Place your bets–A horse race emerges in the migraine space

Currently recruiting for clinical trials:  Amgen’s AMG 334

Status Migrainosus – when the attack doesn’t stop (graphic)

, 3

Status Migrainosus

A person with migraine without aura
has a severe debilitating migraine attack
which lasts longer than 3 days.
Even after temporary relief from medication,
the symptoms remain.


Misdiagnosis is frequent. You may have…

Always see a doctor if symptoms change
or are worse than ever.

Your doctor may recommend:

A few more resources:

Load More

Back To Top
The articles on Headache and Migraine News are © 2004-2025 J. Cottrill.
Every effort is made to ensure the accuracy of each article, and to point you to further sources of information. However, this site is for informational purposes only and should never replace a visit to your doctor.