If oral medication has failed, or you are vomiting, the problem is often not the drug — it is that the drug never got in.
Migraine slows gastric emptying as part of the disease, not as a side effect of it. A tablet taken three hours into an attack can sit in the stomach largely unabsorbed. Vomiting removes the option entirely. Giving the same drug classes intravenously takes absorption out of the equation.
What goes in
The combination is chosen for the attack rather than issued as a fixed recipe, but it is generally drawn from four components:
- An anti-nausea agent such as metoclopramide or prochlorperazine. These are not only for the nausea — the dopamine-blocking antiemetics have genuine anti-migraine activity, which is why they are a mainstay of acute treatment rather than an afterthought.
- Fluids, where vomiting or poor intake has left you dry. Hydration alone rarely aborts a migraine, and we will not tell you it does.
- Magnesium, which has its clearest evidence in migraine with aura and in people who are genuinely deficient.
- An anti-inflammatory such as ketorolac, and in some cases a single dose of dexamethasone — the latter given specifically to reduce the chance of the headache returning over the next day or two.
What does not go in
Opioids. For migraine they are close to the worst available option: they do not address the mechanism, they worsen the nausea, and they interact badly with the antiemetics that do help. They also cross into medication overuse at a low threshold — 10 days a month — and are associated with progression from episodic to chronic headache.
That is a clinical argument about primary headache, not a blanket position. Opioids remain appropriate in other conditions treated here, including head and neck cancer pain.
What the visit is like
You are in a chair, not a bed. An IV is placed, the infusion runs, and most people are here somewhere between one and two hours. Metoclopramide and prochlorperazine can cause restlessness in a minority of people; we watch for it and can treat it directly if it appears. You are not sedated and you can drive yourself home unless we tell you otherwise.
When it is the right call
- An attack that has not responded to your usual oral treatment
- Vomiting that makes oral treatment pointless
- An attack running into its second or third day
- Cover during withdrawal from an overused acute medication, where you need something that does not feed the cycle
That last use is underrated. Unwinding medication-overuse headache means stopping the offending drug while the withdrawal headache peaks, and having a way through that window is often what makes the difference between succeeding and giving up.
What it is not
It is not a preventive. It stops the attack in front of you. If you are having 15 or more headache days a month, the conversation shifts to prevention — see Botox for chronic migraine and headache prevention.
And it is not for cluster headache. That responds to high-flow oxygen, which works in minutes.
Common questions
Why not just take a stronger tablet?
Because the limiting factor is often absorption rather than potency. Gastric emptying slows during migraine, so a stronger tablet can sit unabsorbed just as easily as a weaker one. See IV migraine therapy.
How long does it take?
Most people are here between one and two hours, in a chair rather than a bed. You are not sedated and can usually drive yourself home. See IV migraine therapy.
Will the headache come back the next day?
It can. Where recurrence is a pattern, a single dose of dexamethasone during the infusion is used specifically to reduce that risk. See IV migraine therapy.
Can I have this while withdrawing from painkillers?
Yes, and it is one of the better uses for it, because it breaks the acute headache without adding to the overuse. See medication-overuse headache.
Being seen at Headache Express. We treat migraine, cluster and other severe headaches in St. Louis, usually the same day. Please contact us before coming in so the right treatment is ready when you arrive.
Sources
- Headache Classification Committee of the International Headache Society. ICHD-3, 8.2 Medication-overuse headache. ichd-3.org
A note on coverage, and on timing. Same-day treatment and prior authorization do not run on the same clock. Many insurers take days to weeks to decide, and some acute headache treatments are not covered at all. Your headache will not wait for that process.
We will verify your benefits and, where a treatment needs prior authorization, we will attempt to obtain it. An authorization confirms that a service meets criteria for review — it is not a guarantee of payment, and no clinic can make that promise on your insurer’s behalf. Where something is unlikely to be covered, or cannot be certified in time to treat you today, we will tell you before we treat rather than after, so the decision is yours. Payment is due at the time of service.