Table 3: Medications recommended for severe and ultra-severe migraine attacks | |||
Medication | Dosage* | Main side effect | Level of evidence |
Butorphanol[60,61] | 1 spray (1 mg) in 1 nostril (may be repeated once in 3-5 h) | Nausea, dysphoria, tiredness | I |
Chlorpromazine[54] | 50 mg IM; or 0.1 mg/kg IV by drip over 20 min, repeated after 15 min (maximum 37.5 mg); pretreat with normal saline IV | Drowsiness, extrapyramidal reactions | I |
Dexamethasone | 12-20 mg IV | II-1 | |
DHE[47-52] | 0.5B1 mg q1h IM, SC or IV (maximum 3 times within 24 h) | Chest tightness, nausea, tingling | I |
Ketorolac[23,56-59] | 30-60 mg IM (maximum 120 mg within 24 h) | Somnolence, nausea, dyspepsia | I |
Meperidine[62] | 50-100 mg IM or IV | Sedation, confusion, addiction | II |
Metoclopramide[49,69] | 10 mg IV (if not effective within 20 min follow with 0.5B1 mg of DHE IV, repeated up to 2 mg over 3 h) | Drowsiness, extrapyramidal reactions | I |
Prochlorperazine[55] | 25 mg by suppository (maximum 3 doses within 24 h), or 5-10 mg IV or IM | Drowsiness, extrapyramidal reactions | I |
Sumatriptan[37-47] | 50-100 mg PO (may be repeated twice within 24 h)
6 mg SC (may be repeated once within 24 h) |
Chest tightness, tingling | I |
*The use of antinauseants is recommended as adjunctive treatment (see Tables 1 and 2).
Ketorolac is not approved in Canada for IV use. |