Briefs: Depakote for Migraines

Briefs: Depakote for Migraines

Many a migraine headache is encountered in the ED. The evidence is reasonably clear that the antiemetics (prochlorperazine/metoclopramide – Compazine/Reglan) combined with ketorolac (Toradol) will treat >90% of patients effectively. What about those that don’t respond and are still in (dramatic pause) status migrainosus.

The intravenous dose is 15-20 mg/kg IV (max of 1 gram). It turns out that a faster infusion rate – 10 minutes as opposed to 1 hour that had been given for seizure patients as oral replacement – was more effective. What you do next depends on their response.

The headache is completely gone or substantially improved

Start oral dosing within 4 hours of the IV dose. Generally it is efficient to give this in the ED before the patient goes home. Then prescribe a 14 day course.

  • <10years OR <50kg: 250 mg PO BID x2 weeks
  • ≥10years AND 50kg: 500 mg PO BID x2 weeks

The headache is improved, but not to a satisfactory degree

Repeat a 2nd IV dose within 3 hours. If that works then proceed to oral dosing as above. If it doesn’t then plan for additional therapy – likely DHE and inpatient admission.

Why not Depakote first, well Tanen compared the two in 2003 and noted the following. In a RCT of Prochlorperazine 10mg vs Valproate 500mg the latter was less effective in reducing pain and nausea  (p<0.001). 79% of the Valproate group needed rescue medicine versus only 25% of the prochloroperazine group.

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Again, this is for abortive treatment – not preventative.

By |2016-12-14T12:56:56+00:00January 23rd, 2014|Briefs, Neurology|

About the Author:

Brad Sobolewski, MD, MEd is an Associate Professor of Pediatric Emergency Medicine and an Assistant Director for the Pediatric Residency Training Program at Cincinnati Children's Hospital Medical Center. He is on Twitter @PEMTweets and authors the Pediatric Emergency Medicine site PEMBlog. All views are strictly my own and not official medical advice.

3 Comments

  1. TarHealer January 23, 2014 at 9:14 AM

    Great post! I have given VPA in the ED for status migranosus, usually with neurology involvement. But why the VPA for 2wks post-discharge? Neurology has at times had me start it as a maintenance medicine, but not with a 2wk end date.

  2. Brad Sobolewski, MD, MEd January 23, 2014 at 9:28 AM

    Their explanation of why the 2 week course is beneficial is that the IV bolus rapidly suppresses migraine generating centers in the periaqueductal grey matter, and that this suppression is advantageous to maintain for a short term period thereafter to prevent rebound headaches. Now certainly most rebounds happen within 72 hours. The two weeks – to my knowledge – is as of yet unstudied completely. The decision to go to prophylaxis can then be made at follow up.

  3. […] during any shift in the ED. I have written about them before, and the benefits of antiemetics and depakote are reasonably well documented. A treatment for refractory headaches that seems to be gaining favor […]

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