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.

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