Refractory Migraine - Triptan-Resistant, 45F with BP 140/90

Clinical Context First

Patient declining CT brain: With the clinical picture described (known migraineur, no red flag signs), this is clinically acceptable for now. However, it is important to document the conversation, explain the rationale for imaging, and revisit if the headache character changes or worsens.

Step 1 - Verify: Why Did Triptans Fail?

• Medication overuse headache (MOH): If she has been using triptans >10 days/month for >3 months, they can paradoxically worsen and perpetuate headache. In this case, triptans should be withdrawn, not escalated.
• Wrong triptan / wrong route: Oral triptans have slow onset (1-2 hrs). If not tried, subcutaneous sumatriptan (onset ~20 min) or intranasal zolmitriptan may still work.
• Taken too late: Triptans work best in the early/prodromal phase, not during established headache.
• Hypertension concern: BP of 140/90 is a relative caution for triptans (cardiovascular risk). This makes the case for triptan-free rescue options stronger.

Step 2 - Immediate Rescue Therapy Options

A. Dopamine Antagonists / Antiemetics (First-Line Rescue - AHS 2025 Level A)

The 2025 AHS updated ED guideline now includes metoclopramide + diphenhydramine as a Level A recommendation (must offer).

B. NSAIDs - Parenteral (Strong Option)

• Ketorolac 15-30 mg IV/IM - rapidly effective, non-vasoconstricting, safe with elevated BP. This is a strong choice here given the cardiovascular caution with triptans.
• If oral: Naproxen sodium 500-1000 mg or Ibuprofen 400-600 mg can be tried if not already used.

C. Corticosteroids - To Prevent Recurrence

• Dexamethasone 8-10 mg IV - does not abort the acute headache but significantly reduces the chance of headache recurrence within 24-72 hours. Best used as an adjunct.

D. Magnesium Sulfate

• IV Magnesium sulfate 1-2 g IV over 15-20 minutes
• Particularly useful in migraine with aura (AAFP evidence-based)
• Also has the added benefit of mild antihypertensive effect, which may be useful in this patient with BP 140/90.

E. Valproate Sodium (IV)

• Sodium valproate 500-1000 mg IV over 15-20 minutes
• Moderate evidence; commonly used in refractory migraine. Contradictory trial data but widely used in practice. Avoid in women of childbearing age unless contraception is confirmed (teratogenic).

Step 3 - Triptan Alternatives (Newer Agents for Outpatient Use)

Step 4 - Address the BP 140/90

• BP at 140/90 in a patient in pain is often secondary (pain-driven) and may resolve with adequate analgesia.
• Do not use triptans or ergot derivatives (DHE) in uncontrolled hypertension.
• Recheck BP once pain is controlled.
• If BP remains elevated after pain control, initiate antihypertensive management. Of note, propranolol and metoprolol (beta-blockers) are first-line for both migraine prophylaxis AND hypertension - so they serve a dual purpose here.

Step 5 - Migraine Prophylaxis (Preventive Therapy)

• Propranolol 40-160 mg/day or Metoprolol 50-200 mg/day - first choice, also treats her hypertension

• Topiramate 25-100 mg/day (weight loss is a side effect - may be beneficial)
• Amitriptyline 10-75 mg/night (if no contraindications)
• Venlafaxine 37.5-150 mg/day

• Erenumab, Galcanezumab, Fremanezumab (monthly/quarterly SC injections) - monoclonal antibodies
• Rimegepant or Atogepant (oral gepants) - also approved for prevention
• Consider referring to a neurologist/headache specialist for these

Step 6 - Red Flags to Reassess - Warn the Patient

• "Thunderclap" onset or worst-ever headache
• New neurological deficit (weakness, speech difficulty, visual loss)
• Headache worsening with position changes, Valsalva, or cough
• Fever develops or neck stiffness appears
• No response to any treatment after 48-72 hours

Summary Algorithm for This Patient

Refractory migraine + BP 140/90 + Triptan failure
            |
            v
1. IV/IM Metoclopramide 10mg OR Prochlorperazine 10mg IV
   (+ Diphenhydramine 25mg to prevent akathisia)
            +
2. IV Ketorolac 30mg
            +
3. IV Dexamethasone 8-10mg (to prevent recurrence)
            |
            v
If aura present or partial response:
4. IV Magnesium sulphate 1-2g over 15-20 min
            |
            v
No response after 60 min:
5. IV Sodium valproate 500-1000mg
            |
            v
Discharge planning:
- Oral gepant (rimegepant/ubrogepant) or lasmiditan as future acute Rx
- Start propranolol for prophylaxis (dual benefit for HTN)
- Neurology referral for CGRP monoclonal antibody consideration
- Headache diary, medication overuse check

Key References

• Lippincott Illustrated Reviews: Pharmacology, pp. 1322-1324 (Migraine acute and prophylactic therapy)
• AHS 2025 Guideline Update - Acute Treatment of Migraine in the Emergency Department (Robblee et al., Headache, Dec 2025) - establishes metoclopramide + diphenhydramine as Level A
• ACP 2025 Guideline - Pharmacologic Treatments for Acute Episodic Migraine (Annals of Internal Medicine, March 2025)
• Weant & Gregory, "Pharmacotherapy Management of Acute Migraine in the Emergency Department," Adv Emerg Nurs J, 2025 [PMID: 40929517]
• Mayers et al., "Status Migrainosus - A Narrative Review," Curr Neurol Neurosci Rep, 2025 [PMID: 40715902]

Migraine attack phases and drug options - Lippincott Illustrated Reviews: Pharmacology

Clinical Note on CT Refusal: This is acceptable in a known migraineur with no new red flags. The 140/90 BP warrants monitoring. If she continues to present with refractory attacks or any red flag develops, CT/MRI Brain becomes non-negotiable regardless of patient preference.