Intravenous treatment of migraine

Migraine is a common primary headache disorder. A subset of patients may become disabled by frequent, severe, or treatment-refractory headache. Most patients respond adequately to drugs administered by the oral, intramuscular, or subcutaneous route. Intravenous therapy is an option for the treatment of severe headache in a monitored setting. The most common scenario is the treatment of acute refractory headache in the emergency department. Intravenous treatment may be undertaken with common analgesics, such as acetaminophen, ibuprofen, and ketorolac, or an opioid, or with a drug used specifically for migraine. Among the latter drugs are antiemetic dopamine antagonists, dihydroergotamine, magnesium, valproate sodium, and glucocorticoids. Some of the latter agents have been studied in controlled trials but data are too limited to inform clinical guidelines. Larger placebo-controlled trials of these and other agents will be needed to better position the intravenous drugs in the treatment strategies for acute refractory headache, refractory chronic migraine, and withdrawal headache during the management of medication overuse headache.