Q; 32 year old female is admitted for observation in ICU with severe headache associated with nausea and vomiting. workup in ED and consult with neurology ruled out any subarachnoid hemorrhage(SAH) or any other acute etiology. Patient acknowledge that this headache is similar to her previous episodes of migraine. In view of associated nausea and vomiting, you prescribed 10 mg of IV metoclopramide. Which one other medicine you should add as a part of treatment?


Answer: Couple of doses of IV diphenhydramine

Various treatments are now available for treatment of moderate to severe migraine headache. In migraines associated with nausea and vomiting, very commonly mono-therapy with 10-20 mg of  intravenous metoclopramide or prochlorperazine works well. It is like killing 2 birds with one stone.  Objective of above question is two folds. First, to emphasis that oral agents do not work well in migraine due to gastric stasis causing poor absorption. Second, adding IV diphenhydramine preemptively block any akathisia and other dystonic reactions, which is expected in migraine patients getting treated with metoclopramide or prochlorperazine.



Reference:

Marmura MJ, Silberstein SD, Schwedt TJ. The acute treatment of migraine in adults: the american headache society evidence assessment of migraine pharmacotherapies. Headache 2015; 55:3.