Inpatient chronic headache & migraine regime

Basic set up

Check U+Es, LFTs, Mg++

Quiet dark single room

Avoid caffeine

Monitor observations 2 hourly (sedation)

Watch for opioid withdrawal (mainly codeine): alcohol withdrawal chart observations

Cease opioids, triptans, ergots

IV hydration Hartmann’s 80 mls/hr

IV ketamine infusion 200 mg: ketamine in 200 mls 5% dextrose 5-10 mg/hr; start at 5 mg/hr

IV dexamethasone 6 mg daily

IV maxolon 10 mg QID regular

Continue usual headache/migraine preventive medications including topiramate

Consider pizotifen 4 mg tds po

Vitamin B2 (riboflavin) 100 mg bd po

Magnesium 500 mg daily po

Cefaly cranial TENS machine, 20 minutes 2 x daily prn, and regularly for 20 min at night

Bilateral GON blocks (ropivacaine 0.75%, kenacort 15 mg & clonidine 25 mcg each side)

 

Consider

Memantine 5-10 mg nocte po (to replace ketamine)

Intranasal oxytocin 10 IU QID prn

 

Breakthrough analgesia

IV parcetamol 1g 6/24 prn first line headache

IV parecoxib 40 mg bd prn second line headache

Clonidine 50 mcg 6/24 prn po for anxiety, withdrawal or headache (withhold if sedated; HR<60, SBP< 110)

Lorazepam 0.5 mg 8/24 bd prn s/L for anxiety, withdrawal, severe nausea (withhold if sedated)

IV ondansetron 4 mg 6/24 prn for nausea & vomiting

General educational advice only. No responsibility taken for effects of this information.

EJ Visser 2018 ©