The object of this study was to assess efficacy and tolerability of intravenous (IV) sodium valproate injection (VPA) for the acute treatment of migraine headache. Oral divalproex sodium is widely utilized as a headache preventive. The IV form (Depacon) has appeal as an abortive because of its lack of sedation, cardiovascular effect, and addiction potential.
32 female patients with moderate to severe headache of at least 48 hours duration were treated at the Robbins Headache Clinic. These patients had a long history of refractive migraine headaches. Duration of the headache ranged from 48 to 105 hours. The patients received 500mg of IV VPA, diluted in 5ml of normal saline, over 5 minutes. Only 4 patients were valproate naive. All treatment was outpatient. Relief was assessed at 1, 3, and 24 hours post-injection. Zero to 25% improvement was categorized as no relief, 25% to 80% mild or moderate relief, and complete relief was 80% to 100% improvement.
At one hour, 8(25%) had no relief, 16(50%) mild or moderate relief, and 8(25%)complete relief. After 3 hours, 7(22%) had no relief, 16(50%) mild or moderate relief, and 9(28%) complete relief. After 24 hours, 13(40%) had no relief, 7(22%) mild or moderate relief, and 12(37%) complete relief.
Valproate sodium injection was generally well tolerated. The following side effects were described: Unusual taste sensation (4 pts), somnolence (2), burning at injection site (2), nausea (1), increased headache (1), dizziness (1). Side effects were ransient, except for one patient with somnolence for 8 hours.
For the treatment of prolonged moderate or severe headache, IV VPA is a useful option. This group of patients is often refractive to multiple medications. Valproate is not addicting, and is without significant cardiovascular or respiratory effects. This therapy may also be used in conjunction with other migraine abortives such as triptans, dihydroergotamine, analgesics, or cortisone.
Descriptors: Valproate, migraine, Depacon, Divalproex
Oral divalproex sodium (VPA) is utilized widely as a preventive for migraine and for chronic daily headache1,2. Divalproex sodium has proven to be a safe and effective medication. The intravenous (IV) form of VPA has appeal as an abortive medication because of its relative lack of sedation
and cardiorespiratory effects. VPA does not produce euphoria, and is not addicting.
Many patients suffer prolonged, moderate or severe migraines. These long headaches, which sometimes are menstrually related, often prove difficult to treat. Medication approaches include triptans, dihydroergotamine (DHE), corticosteroids, and analgesics3. Intravenous VPA offers another weapon against these prolonged migraines.
Thirty-two female patients, ages 24-58, with moderate to severe migraine of at least 48-hours duration, were treated as outpatients at the Robbins Headache Clinic. These patients had a long history of prolonged, refractory migraine headaches. In the past, their headaches had lasted days to weeks. Duration of the headaches treated in this study ranged from 48 to 105 hours prior to the IV VPA treatment.
Each patient received 500mg of IV VPA, diluted in 5ml of normal saline injected slowly over a five-minute period. Only four patients were valproate naïve.
Relief was assessed at one, three, and twenty-four hours post-injection. The post-treatment assessments were accomplished via phone interview. Relief was categorized according to the following scale: 0-25% = no relief, 25-80% = mild/moderate relief, and 80-100% = complete relief.
Table I: Efficacy of IV Valproate Sodium Injection (32 Patients)
|Mild or Moderate Relief
Table II: Side Effects
Number of Pts. (N=32)
|Unusual taste sensation
|Burning at Injection Site
Prolonged, severe headache often proves difficult to treat. In the current
study, IV VPA produced complete relief in 25% of patients after one hour,
28% at three hours, and 37% of the patients had complete relief after twenty-four
hours. Many patients with prolonged migraine will improve for a number of
hours with any particular therapy, and then relapse. In this study, IV VPA
appears to have a lasting effect for at least twenty-four hours in certain
A minority of migraine patients suffers chronically from severe, prolonged,
refractory headache. The pain may last days to weeks, and often is associated
with menstrual cycling. Triptans (sumatriptan, naratriptan, rizatriptan,
zolmitriptan) often help, but the headache may recur. Corticosteroids may
stop the headache, but it is necessary to limit the dose due to side effects.
Repetitive IV DHE3,4,5 does help a number of patients, as does
intramuscular (IM) ketorolac. Some analgesics produce sedation, and some
are potentially addicting. Intravenous VPA is well tolerated, and may be
used alone or as an adjunct with other medication approaches. Because VPA
does not affect cardiorespiratory function, it is compatible with triptans
and DHE. The relative lack of sedation allows many patients to receive VPA
and function effectively for the remainder of the day.
Oral divalproex sodium is a widely utilized, effective preventive medication
for migraine6. However, as a migraine abortive, the oral form
has been used with very limited success. The IV VPA achieves effective blood
levels more rapidly than the oral form7. Several previous studies
indicated that IV VPA may be useful for the acute treatment of migraine.
In one study of twenty-four patients, eighteen of whom were valproate
naïve, 300mg of IV valproate sodium was given in 100ml of normal
saline8. Significant headache relief occurred in 88% of those
patients. Onset of pain relief occurred in less than ten minutes in those
who responded. Ten of the twenty-four patients reported complete relief within
ten to twenty minutes. The authors state that rapid infusion of IV VPA yielded
A second study with twenty patients was accomplished giving either 500mg
of IV VPA over fifteen to thirty minutes, or DHE IM, with
metoclopramide9. In the IV VPA group, headache relief after one
hour was 60%, versus 40% in the DHE plus metoclopramide group. After four
hours, IV VPA produced headache relief in 70% of patients versus 60% in the
Intravenous valproate sodium should result in comparable Cmax
and Cmin when compared to the oral formulation. The
Tmax of IV VPA occurs at the end of infusion, compared to about
four hours after oral administration. The oral and intravenous forms are
roughly bioequivalent7. The liver metabolizes valproate, and
monitoring of the drug level and liver function tests is done on maintenance
oral valproate therapy. It also is prudent to monitor platelets. However,
with single dose IV administration, this should not be necessary. Valproate
generally should not be given in any form to patients with compromised liver
function. Valproate should not be given during pregnancy. Women of child-bearing
age should be screened for pregnancy before use of the drug, and cautioned
about the teratogenic potential of the drug if pregnancy should occur during
Intravenous valproate sodium was well tolerated in the current study. Previous
studies, n=463, recorded the following more common adverse reactions: dizziness
(5.2%), headache (4.3%), injection-site reactions (2.4%), injection-site
pain (2.6%), taste perversion (1.9%), and somnolence (1.7%) 7.
Intravenous valproate sodium may be effective for certain patients in the
acute treatment of prolonged, severe migraine headache. Double blind studies,
with controls, are necessary to assess this therapy more fully.
This study was supported by a grant from Abbott Laboratories.
Acknowledgements: The author wishes to thank Charles Ludmer, MD, and Halleh Akbarnia, MD, for their editorial help.
- Ghose K. Efficacy and safety of long-term sodium valproate therapy in the prophylaxis of migraine headache. Headache Q 1999; 10:127-130.
- Silberstein SD. Divalproex sodium in headache: Literature review and clinical guidelines. Headache 1996; 36:547-555.
- Robbins L. Management of Headache and Headache Medications. New York: Springer-Verlag, 1994: second edition 2000.
- Raskin NH. Repetitive intravenous dihydroergotamine as therapy for intractable migraine. Neurology 1986; 36:995-997.
- Robbins L, Remmes A. Outpatient repetitive intravenous dihydroergotamine. Headache 1992; 32:455-458.
- Ghose K, Niven B. Prophylactic sodium valproate therapy in patients with drug-resistant migraine. Meth Find Exp Clin Pharmacol 1998; 20:353-359.
- Depacon [package insert]. Abbott Park, III: Abbott Laboratories.
- Kailasam J, Mathew NT, Meadors L, Chernyshev O, Gentry PS. Intravenous valproate sodium (DepaconTM) aborts migraine rapidly: a preliminary report [abstract]. Headache. 1999:361.
- Edwards KR, Santarcangelo V. Intravenous valproate for acute treatment of migraine headache [abstract]. Headache. 1999:353.