Migraines remain a common presenting complaint in the emergency department. Accounting for 2.1 million visits annually, they can be one of the most frustrating conditions to take care of.1,2 Nearly 45 percent of migraine sufferers receive the wrong treatment in the emergency department, which may lead to poor patient satisfaction and frequent bounce backs.3 When your department’s “migraine cocktail” doesn’t work and you’ve even tried dipping into some dexamethasone or sumatriptan without much success, you are probably out of options. Most emergency physicians around the country are comfortable with using propofol for rapid-sequence intubation and procedural sedation, but what about for migraines?
A group working in an outpatient headache and pain clinic was the first to accidentally discover the beneficial effects of propofol on intractable headaches.4 Krusz et al began noticing a trend after their patients were given a preprocedural dose of propofol for its anxiolytic and antiemetic properties: the patients’ headaches would nearly disappear.4 This occurred in six patients prior to receiving a nerve block. The group then began to study this treatment more formally. They enrolled 77 patients who had a refractory headache unresponsive to their typical rescue medication regimen from their outpatient clinic. Propofol was administered in 20–30 mg boluses every three to five minutes intravenously, with an average total dose of 110 mg needed to completely abolish the headache or achieve maximal reduction. There was a pain reduction of 95.4 percent on a 0–10 visual analog scale (VAS) in the 77 patients enrolled, with 82 percent having complete resolution of their headache. Unfortunately, the doses were not reported as mg/kg doses, which makes it difficult to apply to different populations, but they did report that none of their patients fell asleep or lost consciousness during treatment with propofol. This study gave rise to multiple case reports and even some randomized trials.
Nearly 45 percent of migraine sufferers receive the wrong treatment in the emergency department, which may lead to poor patient satisfaction and frequent bounce backs.