Anatomy of a Headache

Dr. Robbins Free Medical
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Long-Acting Opioids for
Refractory Chronic

Study results for a group
of difficult-to-treat
migraineurs provide a
basis for determining
efficacy and guidelines
for the use of long-term
opioids in this


Heatherís Chronic
Migraine: an Interactive
Case History

This column will take you,
step by step, through
the diagnosis of a complex
headache patient with
the pseudonym of "Heather."



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Outpatient Repetitive Intravenous Dihydroergotamine
Lawrence Robbins, M.D., Anne Remmes, M.D.
Posted: January 2010
Headache  1992;32:455-458

The efficacy of the repetitive intravenous dihydroergotamine (DHE) inpatient protocol for refractory headache is well established. We conducted a retrospective and prospective study of long-term headache patients at our clinic to evaluate this regimen in an outpatient setting.

Treatment consisted of oral metoclopramide and four doses of DHE, with the total dose equaling 4 mg., administered over two days. Patients were followed for up to 10 weeks while they continued to receive prophylactic medication. Responsiveness was rated in terms of decreased frequency or severity of headache: excellent (75-100%), moderate (50-75%), mild (25-50%), and none (0-25%).

In the retrospective study, 69% of patients with chronic daily muscle-contraction-type headache and severe migraine had an excellent response at two days. An excellent or moderate response was sustained over three weeks in 65% of the study group. At the 6- and 10-week follow-up evaluations, the majority of patients reported mild or no relief.

Among patients with refractory daily headache or frequent severe migraine studied prospectively, 80% reported an excellent response at two days. After six weeks, 66% showed excellent or moderate relief. For both groups combined, 73% of patients showed an excellent response to DHE at two days, with 43% sustaining excellent or moderate relief at six weeks. Side effects, including nausea, leg cramps, facial flushing, increased blood pressure, diarrhea, burning at the injection site, and tightness in the throat and/or chest, were generally mild and transient. Side effects were milder with outpatient DHE versus our experience with inpatient DHE.

Outpatient repetitive IV DHE treatment offers flexibility in the management of severe headache. Our studies demonstrate the safety and efficacy of this regimen.

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