Acute Migraine Rescue With Propofol, Lidocaine, Anti-epileptics
Migraines are a frequently disabling disorder that may require inpatient treatment. Admission criteria for migraine include intractable migraine, nausea and/or vomiting, severe disability, and dependence on opioids or barbiturates. The inpatient treatment of migraines is based on observational studies and expert opinion rather than placebo-controlled trials.
Well-established inpatient treatments for migraines include dihydroergotamine, neuroleptics/antiemetics, lidocaine, intravenous aspirin, and non-pharmacologic treatment such as cognitive-behavioral therapy.
Short-acting treatments possibly associated with medication-overuse, such as triptans, opioids, or barbiturate-containing compounds are generally avoided. While the majority of persons with migraine are admitted on an emergency basis for only a few days, outcome studies and infusion protocols during elective admissions at tertiary headache centers suggest a longer length-of-stay may be needed for persons with intractable migraine.s
We Offer The Folowing Migraine Treatments
Intravenous propofol in both subanesthetic and sedating doses has been reported to be effective for acute migraine in outpatient and emergency department settings. In a small study conducted in an inpatient setting for airway monitoring, 18 patients with chronic daily headache (14 with chronic migraine) were treated with repetitive boluses of propofol with a mean total dose of 234mg. Six achieved headache freedom and 11 reported reduced headache intensity with a mean decrease of 4.2 points on a 10 point scale. There were no adverse events other than drowsiness, and in fact, patients who slept between boluses had more pain relief.
Two retrospective reviews have examined the use of intravenous lidocaine for chronic migraines. Of 71 patients with chronic daily headache (90% with migraine) and medication overuse treated with lidocaine infusion at 2mg/min for seven to ten days, 90% noted improvement in headache by discharge, with 60% achieving headache freedom .
Six months later, a headache was absent in 51% and improved in an additional 20%. Of 68 patients with chronic daily headache (60% with migraine) treated with between 1mg/min to 4mg/min of lidocaine for a mean of 8.5 days, 57% had some improvement, and 25% achieved headache freedom . Most patients had received intravenous DHE, neuroleptics, or corticosteroids during the hospitalization prior to lidocaine. Side effects were generally mild, including nausea, hypotension, and arrhythmia, and did not lead to treatment discontinuation. However, hallucinations  and other psychiatric side effects are not uncommon.
Antiepileptic drugs (AEDs) are frequently used as a preventive treatment for the management of migraine. Topiramate (TPM) and valproic acid (VPA) are 2 AEDs that have demonstrated efficacy in reducing the frequency of migraine attacks, and both carry US Food and Drug Administration indications for the prevention of episodic migraine, based on level A evidence.