Migraine Treatment: IV Magnesium Sulfate

When migraine has gone on too long, or is too painful to bear and other medications and treatments have failed, patients often think “It’s time to bring out the big guns” and opt for powerful painkillers instead of other more helpful treatments less likely to cause medication overuse headache. 

The emergency room versus a specialist

When visiting the emergency department, patients are often offered drugs that might provide short-term relief from the pain but do nothing for the attack itself. Suppose we can stop an attack in progress. In that case, the pain will go away. This is the approach migraine specialists take, often utilizing a very simple approach that can work quickly and extremely effectively.

What is magnesium sulfate used for?

Magnesium sulfate is a drug/nutrient we’ve talked about here before. It is used in a hospital setting for serious conditions in addition to migraine, including:

• Life threatening asthma attacks
• A heart rhythm problem called torsades de pointes which can result in heart attack
• Pre-eclampsia
• To delay labor in preterm situations

What does it do?

Magnesium sulfate also reduces inflammation, relaxes muscles and blood vessels as well as modulates calcium ion channels within our cells which trigger the release of neurotransmitters.

Deficiencies in migraine patients

Migraine patients were found to be more likely than non-migraineurs to be magnesium deficient when their blood is tested. However, even this doesn't show the magnitude of the problem because magnesium levels are difficult to maintain in tissue, especially the brain. Labs that check only our blood levels may appear normal in the presence of a deficiency in our central nervous system.

Hospital protocols

Many hospitals have a protocol they use for migraineurs that utilize magnesium sulfate first, before pain meds are offered. Sometimes mag sulfate is given in addition to pain medication.

My headache specialist's protocol

My headache specialist has a protocol she likes her patients to try. She gives patients a sheet with the protocol listed so that if an emergency department visit becomes necessary, they have specific information to give to the ED staff.

How was it administered?

My doctor’s protocol for administration of mag sulfate is:

1. 1 gram magnesium sulfate given intravenously, unless otherwise specified.
2. Dilute the magnesium sulfate 1 gram with 0.9% sodium chloride for a total volume of 10cc. Solution should not be used if discolored or if it contains precipitate.
3. Magnesium is to be administered IV push over 3-5 minutes
4. Vital signs (BP and pulse) should be obtained at baseline and after administration.

I have had mag sulfate used under the direction of other physicians as well. In those cases, instead of IV push using a syringe, my mag sulfate was put into a saline IV bag and given over the period of 30 minutes. This is often done because magnesium can be irritating to veins.

What are the side effects?

Possible side effects of mag sulfate include:

• Facial flushing
• Hypotension
• Lightheadedness
• Diarrhea

Symptoms of hypermagnesemia

Hypermagnesemia may develop if administered chronically (repeatedly in a relatively short period of time). Symptoms of hypermagnesemia include:

• Nausea
• Sedation
• Hypoventilation
• Muscle weakness
• Decreased heart rate

Using the ER only in an emergency

As advocates we try to remind patients that the emergency room is often not our friend and should only be utilized only necessary or in the case of an emergency.

There's a stigma in the ER

If what we're experiencing is a worse than normal migraine, but otherwise the symptoms are the same as our usual attacks, doctors will often not be happy to see us in their department. When migraineurs then ask for narcotic pain relief, this can raise red flags for staff, calling into question the reason for the request for addictive drugs.

How does magnesium sulfate help?

Knowing about and utilizing magnesium first can often show staff that a patient is not only educated about their disease but also willing to try something other than narcotics to help themselves. It can go a long way if the magnesium fails when doctors who are now more willing to trust you are subsequently asked for pain relief.