As droperidol goes back on shortage, I wanted to give a brief review of primary headache treatments. Most therapies for primary headaches have a ~60% rate of pain relief, and there is no predictable overlap between drug classes, so if one class doesn’t work, try another class of medications.

1. Triptans:  The constellation of symptoms and their duration do not appear related to the effectiveness of these medications for any primary headache, so use them on any of them in patients who aren’t pregnant and don’t have cardiac risk factors putting them at risk from its transient vaso-spastic effects
   1. Ellitriptan (Relpax) 40 mg po, this should be your first line in the ED, multiple studies have shown it to be as effective as sub cutaneous sumatriptan and better than the other oral ones.
   2. Sumatriptan 6mg sub cu, no more effective than Relpax but comes in a shot. Don’t use the oral version.
2. Dopamine Antagonists
   1. Droperidol: 2.5 mg IV and 5 mg IM have been shown to be superior to other drugs in the is class, the principle side effect is sedation, which is far more common than akithesia when we have studied it here, so keep that in mind when deciding whether to pre-treat with Benadryl.
   2. Olanzapine 10 mg IM: Found it to be similar to droperidol in a 2008 study.
   3. Compazine 10 mg IM/IV less effective than droperidol similar to reglan for effectiveness and side effects.
   4. Reglan 10 mg IV less effective than droperidol same as Compazine for side effects.
3. Sleep Inducing Agents
   1. Secobarbital: has great data for relieving headaches but its not on our formulary, send patients home with a dose, they take it in bed and wake up without a headache.  I’ve tried this with headache who failed triptans and don’t want droperidol using ambien 10 mg with some success.
   2. Benzos: the shorter acting the better, inducing sleep is the goal.

Compiled by Dr. James Miner, Associate Professor, Department of Emergency Medicine, Hennepin County Medical Center.