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IV Therapy in the Headache Clinic for Refractory Migraine

Aggressive Outpatient Therapy versus Inpatient or Emergency Department Treatment


Updated: November 15, 2005

Intractable or refractory Migraines are those that don't respond to treatment. This can lead to desperation on the part of the patient and frustration on the part of their physician. Intractable and refractory Migraines need aggressive treatment, but few doctors are prepared to offer such treatment. That's not an indictment of any doctor, simply a statement of fact. With the exception of true headache and Migraine specialists, doctors simply have too many conditions to treat to be expected to have the expertise to treat such cases.

John Claude Krusz, PhD, MD; (Ask the Clinician) and his colleagues; Virginia Scott-Krusz; Jeanne Ballanger, RN; and Jane Cagle, LVN; have been using outpatient IV treatment for refractory Migraines in Dr. Krusz's Dallas clinic since 1994 and collecting research data.


    "The future of aggressive headache treatment is in the specialty clinic, a far more cost- and time-effective mode of treating intractable headaches, including refractory and chronic Migraines. Compared with the emergency department, the headache clinic can offer a wider range of effective and definitive treatments and offer headache patients maximum degree of success for control of Migraines. We have used IV treatment in the clinic since 1994 and presented initial data regarding its effectiveness in 1998. This study continues in documenting the degree of success of outpatient IV treatment of headaches.

    Our total treated patients number over 1700. Of these, 874 were treated for refractory Migraines or headaches; the rest were for pain flare-ups or a mixture of both.

    We utilized the following treatments: IV magnesium sulfate, dexamethasone, valproate sodium, lidocaine, droperidol, dihydroergotamine, promethazine, propofol, tramadol, levetiracetam and ketamine. Results are measured on the basis of successful resolution of symptoms, defined by at least a 50% decrease in severity of the presenting headache or Migraine, or by return to work or regular activity. On this basis, 62 patients from the total pool, and 22 from the headache pool (22/874) [2.5%] had unsuccessful treatment that required re-treatment in the clinic, hospital ED or inpatient. This represents a 97.5% rate of effective treatment in the clinic setting.

    We conclude that outpatient aggressive therapy of refractory headaches and Migraines is highly successful with a very low need for retreatment. It contributes to productivity, most importantly in the workplace and also at home and in personal life.*"

It has been the theory and experience of some head pain and pain management specialists that head and other pain flare-ups could be better managed aggressively in an outpatient setting rather than inpatient or emergency room settings. Such treatment is dependent upon the outpatient clinic being set up for the appropriate treatments. Krusz et al believe and have demonstrated that this treatment is more effective for and preferable to the patient, being less expensive and offering more options that can be offered in an emergency department setting. Based on the results of their work, they urge headache and pain practitioners to incorporate these IV treatment techniques when they are seeing a patient with refractory headache or Migraine.

Combinations - "It seems like virtually every combination of IV medications at our disposal has been tried or given in my clinic at one time or another for refractory Migraines, headaches or a combination of these with a pain flare-up. Of course, we make every effort to use one medication at a time and to document carefully the percentage reduction to that single agent...*"

Conclusions of This Research:

  1. "Outpatient aggressive therapy of refractory headaches and Migraines with IV therapies is highly efficacious with a very low need for re-treatment.
  2. Our series successfully treated refractory Migraine and other headaches 97.5% of the time [852 of 874 patients].
  3. Treatment in this manner contributes tremendously to productivity, most importantly in the workplace, at home and in personal life for the Migraine sufferer.
  4. We would urge headache specialists and physicians interested in the acute management of headache disorders to explore these options in their practices.*"

It's difficult to add much to the conclusions above. I would, however, add that such outpatient therapy is also highly desirable as such treatment is achieved far more quickly and with far more dignity than in an emergency room setting. Hopefully, this research will lead to more doctors adopting this type of therapy for their patients.

>> For more details on this research and to view the poster presentation referenced below, click HERE.<<


* Scott-Krusz, Virginia; Balanger, Jeanne, RN; Cagle, Jane, LVN; Krusz, John Claude, PhD, MD. "Effectiveness of IV Therapy in the Headache Clinic for Refractory Migraines." Poster presentation to the European Federation of Neurologic Societies; Athens, Greece. September, 2005.

Published: November 15, 2005

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