Rescue Medications

RATE

In acute treatment of migraine, a rescue medication is one that can be taken at home when other treatment options are not successful. Such medications may provide migraine relief without requiring the patient to visit the clinic or emergency department.[1] Rescue medications may also be used in the setting of the clinic or emergency department to treat migraine that does not respond to first-line acute treatments.[2]

Outpatient and Emergency Rescue Treatments

A migraine patient may experience a migraine episode lasting for an extended period of time (≥72 hours) that does not respond to ordinary acute medication options and requires rescue treatment. For rescue treatment in the outpatient setting, effective alternatives may include subcutaneous sumatriptan, dihydroergotamine (DHE) nasal spray dosed repetitively, or a brief course (several days) of a steroid, such as dexamethasone, with the goal of rendering the patient headache-free for 24 hours. Other options include repetitive dosing of triptans or a long-acting ergotamine such as methylergonovine.[2]

Rescue options for the clinic or emergency department setting include a range of intravenous (IV) or intramuscular medications, including triptans, ergotamines, antiemetics, NSAIDs (eg, ketorolac), steroids (eg, dexamethasone), anticonvulsants (valproate), as well as IV magnesium (Table 1).[2]

Table 1. Parenteral Acute Migraine Treatments for Use in Clinical or Emergency Department

Medication

Dose

Route

Other Facts

Dihydroergotamine

Maximal subnauseating dose up to 1 mg

SC, IM, IV

May be mixed with lidocaine in SC or IM dosing; recurrence is low; nonsedating; contraindicated with vascular disease
Sumatriptan

4 mg, 6 mg

SC

Nonsedating; contraindicated with vascular disease
Metoclopramide

10 mg

IV

Risk for extrapyramidal effects and mild sedation
Promethazine

25 mg to 50 mg

IM, IV

Risk for extrapyramidal effects and Sedation
Prochlorperazine

10 mg

IV

Risk for extrapyramidal effects and Sedation
Droperidol

2.5 mg to 5.0 mg

IV

Risk for QT prolongation, extrapyramidal effects, hypotension, and sedation
Ondansetron

4—8 mg

IV

Nonsedating antinauseant
Ketorolac

30 mg IV, 60 mg IM

IM, IV

Nonsedating, risk for GI bleeding
Dexamethasone

4 mg to 10 mg

IM, IV

Nonsedating
Valproate

500 mg to 1000 mg

IV

Nonsedating
Magnesium

1 g

IV

Nonsedating; works best for patients who have migraine with aura
From Tepper SJ, Spears RC. Neurol Clin. 2009;27:417-27.