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“You can get past the dead end. You can break through the ceiling. I did and so have countless others.”

Clinical Pearl Wednesday #40

Best Nurse Practitioner

Have a patient presenting to your office with an acute migraine? Have they tried everything they could such as NSAIDs, Tylenol, triptans etc.?

My go to migraine injection cocktail includes Toradol 60mg (ketorolac), Zofran 8mg (ondansetron), and Benadryl 50mg (diphenhydramine). After I give the patient this, I have them rest in the room with the lights off for 30 minutes.

I would estimate that 80% of the time the patient experiences significant relief, but be wary, the migraine can rebound! Therefore, I follow this up with Decadron 8mg (dexamethasone).

For the other 20% of patients who have more severe migraines, you will need to use other medications instead. Some patients do not respond to Toradol. Many of these people have become desensitized to NSAIDs because they use them chronically. I have found that an injection of Nubain 5-10mg (nalbuphine) instead of the Toradol works well for these individuals. Be cautious though, this is an opioid agonist/antagonist and should be considered a last resort.

Many other times, it is just the nausea that becomes overbearing to the patient. While Zofran works most of the time, it does not help with the nausea in some migraine patients. Either Reglan 5mg (metoclopramide) or Phenergan 25mg (promethazine) work well for the migraine associated nausea.

As always, use your own clinical judgement and understand new medications thoroughly before ordering them!

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