S2:Ep20 – IV Therapy for Migraine Rescue Treatment



Voice-over: Welcome to Spotlight on Migraine, hosted by the Association of Migraine Disorders. Join us for fresh perspectives by medical experts and advocates as we explore the spectrum of migraine and dig deeper into this complex disease. This episode is brought to you by our generous sponsor, Lundbeck.


Dr. Dan Henry and nurse practitioner Ruth Kennedy walk us through the process of getting IV therapy, a treatment method they use to help break a migraine attack that hasn’t responded to other therapies. They explain the medications that are used, who it’s best for, where to get it, the cost, and more.


Lundbeck is a global pharmaceutical company that is committed to improving the lives of people living with brain diseases. Lundbeck is pleased to offer a treatment option for migraine prevention. To learn more, visit LundbeckUS.com.


Molly O’Brien: Hello and welcome to Spotlight on Migraine. I’m your host, Molly O’Brien. Today you’re going to learn everything you need to know about IV therapy for migraine. I’d like to introduce our guests, Dr. Dan Henry and Ruth Kennedy of the Foothill Family Clinic.


Hello, and thanks so much for joining us.


Ruth Kennedy: Hi.


Dr. Dan Henry: Thank you for having us.


Ruth: Thank you for having us.


Molly: First, let’s start off with the basics. What is IV therapy?


Dr. Henry: The IV therapy is basically exactly that: it’s starting an IV line, which is not a big deal, with fluids and everything, and it’s used predominantly — or, we use it predominantly for rescue. And these are for patients who have been using their normal oral or injectable rescue meds and they’re just not getting anywhere. And maybe they’ve got intractable migraine. They’ve gone two, three, four, five days or more with continuous headaches, but it just doesn’t knock it out.


And so we start an IV and give various medications. Some people call them migraine cocktails. And so we can give them all sorts of different medications through the IVs. And one thing is a lot of these individuals have been very nauseous. They may have been throwing up. They may be very dehydrated. So the fluids in and of themselves are very useful.


Molly: So that’s kind of the basic overall. So now let’s get into the nitty-gritty. But we did have a question while we were preparing this podcast: Is IV therapy different from CGRP therapy that also uses an IV? Some of them do.


Dr. Henry: Yeah, one of them does. And, yes, it’s totally different than that. This is used more to break a cycle, to break somebody who’s intractable, and this is to get them relief right now. And so we kind of have a number of different cocktails that we use. We start off with high-dose magnesium in the IV, magnesium sulfate, which is a nerve kind of calming agent and works in and of itself. But then we add pain medication, oftentimes Toradol. We offer different anti-nausea medications with it. And then in some people who are severely intractable, we’ll use IV dihydroergotamine, or DHE. 


Molly: Can you walk us through kind of what the process looks like, feels like, sounds like, what people can expect if they’re looking for this kind of treatment.


Ruth: Yeah.


Dr. Henry: Ruth just walked a patient who’s on it right now in another room, so.


Ruth: I just hooked somebody up back there. Yeah, so somebody comes in. Usually, they’ve called first, and they’re like, “I can’t get rid of this headache. I’ve taken my medicine.” And we kind of talk about options. So number one, I say, “Did you drive here, or do you have somebody to drive you?” So then we can figure out do we want to give medications that can make you tired or not. And then we talk about medicine allergies, because I don’t want to give you anything you’re allergic to. 


And usually what we’re doing is we have to find IV access, so that’s usually a vein in your arm. It’s just one little poke. It’s not as bad as a flu shot, I don’t think. But then we can kind of get the fluids going. And especially in a migraine when you’re having that nausea and vomiting, you’re already dehydrated, and that’s feeding the migraine more.


So a lot of people start to feel better almost right away, just because they’re like, “Ahh.” It’s so hard to drink enough when you’re very nauseated. And most IV medications, they kick in much more quickly than oral medications do. So if you’re taking an ibuprofen, that may take 20 minutes, 30 minutes in some cases. And we know with migraines, a certain number of people, their digestion kind of slows down, so you’re not absorbing quite as well as when you don’t have a migraine.


So with the IV, you know you’re going to absorb it. You know it’s going to kick in more quickly. Most of the medications, I feel like none of the hurt. I can kind of taste a metallic taste with some of them. But overall, besides the needle poke of putting the IV in and a little fluttery of the fluid kind of going in, it really doesn’t hurt. 


It does take a little longer. It’s a longer appointment, so you plan on being here in the office for one or two hours. If you have somebody who can drive you, that’s great, and we may give you Benadryl or something, because a lot of people who’ve had a migraine for a few days aren’t sleeping well. So it’s helpful to maybe be a little sleepy. But if you drive yourself or don’t have a driver, I think it’s just as effective.


Dr. Henry: We can do nerve — if we have somebody who’s really intractable — I mean, they really have stubborn migraine and nothing’s working on it — we can give them an IV and do nerve blocks even at the same visit. And we do that quite commonly, actually. And we can give them steroids also in addition. I mean, the myriad of antinauseas we use, typically either metoclopramide or promethazine or sometimes ondansetron, Zofran, we can give any of those medications intravenously. 


And they kick in — typically, I tell people — on the first IV bag, because depending on how dehydrated they are, we may give them either one or two liters, so a lot of fluid. But we can give that, again, about an hour and a half, but I usually tell them that typically by about half the first bag, they’ll start to notice their headaches and their nausea, it’s much, much better. And so that doesn’t take very long.


Molly: That’s pretty fast relief, or at least the start of relief, especially if you’ve been intractable for several days or weeks. That makes a big difference.


Dr. Henry: Oh, huge, huge.


Ruth: Yeah, huge.


Molly: And you told us that the patients that you offer this type of treatment to are intractable. They just can’t get rid of migraine. Can you tell us a little bit more about who might be best served by this treatment, and then on the flip side of that, who should not be a candidate for IV therapy?


Ruth: I think the people who are best served by this — if you have a lot of nausea with your migraine or you frequently throw up, IVs are for you. Because once you’re throwing up, it doesn’t matter how great a pill is; you’re not going to absorb it. And then any time you’ve taken your rescue medicine, maybe even three days in a row, and you’re just still not getting rid of it. 


We prefer people to come in sooner than later. The people who come in and are like, “I’ve had this for two weeks,” we’re like, “You probably should have come in sooner.” We’ll fix it, but it’s a little easier earlier.


Dr. Henry: We don’t want them to suffer.


Ruth: Yeah.


Dr. Henry: I mean, let’s face it. We don’t —


Ruth: Two weeks is a long time, yeah.


Dr. Henry: Yeah, that’s a long time. And, typically, if you go two, three days in a row, you’re probably not going to break it just doing the same thing you’ve been doing —


Ruth: Right.


Dr. Henry: — for the last few days.


Ruth: Right.


Dr. Henry: And so you need something more.


Ruth: Yeah. And even some people — you don’t have to be throwing up or very, very nauseous. There’s some people who just — they’ve exhausted their meds, and so an IV, it’s a different thing we haven’t tried yet. It’s other medications they haven’t been given. And so, honestly, almost anybody can.


I think the people who aren’t served well — what do you think?


Dr. Henry: Well, the person who’s had it — they’ve never had an IV, but they’ve heard a friend who had an IV, and they’ve had a migraine for three hours, right? 


Ruth: Right.


Dr. Henry: We’ll get those calls.


Ruth: It’s overkill.


Dr. Henry: And they want to come in for an IV, and you say, “Well, let’s start with something else.”


Ruth: Right.


Dr. Henry: But otherwise, almost nobody is not a candidate for IVs. 


Ruth: Yeah.


Dr. Henry: And just to give you an example, I mean, as you heard with the last conversation, we do a lot of acute care here, meaning patients who call the same day, but they’re just having a horrible time.


Ruth: And I guess probably the only other rare contraindication is if you had kidney disease or kidney failure. We’d probably do it either slower or a lower volume. So we take into account any other preexisting health conditions like that.


Dr. Henry: And pregnancy, you have a whole different — because you’ll get some severe migraineurs in pregnancy, and their migraines may be very, very severe. And you don’t have as many options, but you can do just the fluid for a lot of those patients who are pregnant and throwing up a lot. The fluids add a lot. And the nerve blocks add a lot to those people.


We can’t do some of the medications, but we can do ondansetron, certainly. We can do metoclopramide, both for both the migraine and for the severe nausea. And that’s huge.


Ruth: Really helpful.


Molly: It sounds like what you’re describing is a really good last-ditch effort to get rid of migraine, so it’s nice to know that there’s a little bit of a catch there when you just can’t seem to knock it on your own.


Dr. Henry: Oh, absolutely.


Molly: So you talked a little bit about how patients can start feeling relief within about 30 minutes or half of an IV bag. Do you have any understanding of what the efficacy is or how many patients actually do respond?


Dr. Henry: At least 90 percent of people, by the time they leave, are probably 75 to 80 percent improved over when they walked in.


Ruth: Yeah.


Dr. Henry: And that may be underplaying it. It may be better than that. But it’s a very, very effective rescue medication — or, rescue regimen, because it’s not just a med, because there’s lots of different medications we use. And the key is, you’ll find certain people respond much better to one regimen, and others respond better to another, but you can add these together and find out. So, really, you can really formulate a plan for a specific patient and individualize it. It’s not one size fits all.


Molly: Rarely it is. That would make things too —


Dr. Henry: Yeah. Not with migraine.


Ruth: Never with migraine.


Dr. Henry: Never with migraine. Never with migraine, yeah.


Molly: It would just be too easy that way. But it sounds like most patients get pretty good results. I mean, if you’re shooting at 90 percent of patients get 75 percent relief by the end of treatment, that’s pretty darn good. So good for us to get that information out there.


Now, like you said, most treatments are individualized for each patient, but I am wondering if you know of any side effects or if you’ve seen any side effects or interactions with other migraine medications that could be problematic.


Dr. Henry: Most of the individuals, you talk to about what they’ve taken in the last day and that same day, before — in other words, you’d never give — if they had taken a triptan, Imitrex, one of these triptans, right before they came in, you’d never give them DHE, dihydroergotamine, because that can lead to hypotension and there’s drug interaction there. 


But most of the other medications that we’re using, there aren’t major drug interactions. The most common side effect we see is drowsiness, and that’s only in patients who have a driver, and we’ll give them medication that we actually don’t mind if they fall asleep during the IV. In fact, a lot of them will.


Ruth: Yeah.


Dr. Henry: Actually, they’ll take a nap, and that’s always a good sign because you know you’ve pretty much broken them if they’re asleep.


Ruth: Sometimes it is a little bit of trial and error, so I like to talk a lot about possible side effects. Like Zofran, it’s a very well-tolerated anti-nausea medicine. One or two percent of patients can get constipation with it, so I like to give people the heads-up that that’s a possibility. But we use these medications so much, we’re very familiar. But in terms of reactions between medications, most do pretty well.


Dr. Henry: Yeah. There’s a rare extraparametal effect where somebody has a very uncomfortable sensation, but those are — yeah. I mean, they’re so rare, and there’s easy ways to combat them as long as you know what you’re looking for.


Molly: Good to know. So now we’ll get down to the really fun part, cost of IV therapy. Is this something that’s covered by some insurances? If not, what are you looking at if this is the kind of treatment that you are seeking out?


Dr. Henry: Number one, it is covered by almost all insurances, and most of the insurances love the fact that we do it in the office, because we can do it for maybe 25 percent the cost of what it would be in the ER, maybe closer to 10 in some ERs. So it’s actually a very cost-effective treatment.


Molly: So can you explain a little bit about cost if someone doesn’t have insurance, maybe throw out a couple numbers for us?


Dr. Henry: Typically, if they don’t have insurance, maybe $200.


Ruth: Worth it.


Dr. Henry: Where in the ER, it might be $1,200 or more.


Ruth: And I feel like even with insurance coverage, the price range is usually anywhere from fully covered to about 200.


Molly: I’m curious — because people around the world listen to these kinds of interviews — how can they approach seeking out IV therapy? Do they talk to their doctor? Do they make calls to different clinics? How do you go about getting this treatment if you haven’t done it before?


Dr. Henry: Yeah, you always want to start with your own doctor, and if you have a headache specialist or whoever your doctor is that you see for your migraine disease, that’s the first place to start. And a lot of them, I will tell you, don’t do IV therapy in their own facility, but a lot of them have association with an infusion center or some place that’s, again, more cost-effective and quicker than going to an ER on a cold run. I mean, some patients will still end up in the ER because it’s 2 o’clock in the morning and things like that, but the vast majority of people can be treated as an outpatient center that’s a lot more affordable and maybe a little more efficient.


Molly: These are all good things to know for migraine patients out there that they don’t have to live with intractable migraine. There are options.


Dr. Henry: There are options, absolutely. 


Ruth: There are.


Molly: So good to know. I do have a couple questions from our audience. One listener is curious if IV therapy would work for vestibular migraines.


Dr. Henry: Yes. We use it commonly.


Molly: Good to know. Another one of our audience members is curious if they seek out IV therapy and it doesn’t work, what could they do next? And I know you don’t have this patient, but kind of broadly speaking, if it doesn’t work for a patient, then what?


Dr. Henry: If they do IV therapy and they’re not doing great at the end of the appointment, we’ll commonly do nerve blocks with those people or give them a short course of steroids, prednisone, to break the cycle. There are a lot of other rescue things you can do in those individuals.


Molly: So I’d like to wrap things up here on Spotlight on Migraine, and I’d like to thank our guests, Dr. Dan Henry and Ruth Kennedy, so much for joining us today. It was great to see you all again.


Dr. Henry: Good to see you.


Ruth: Thank you so much for having us.


Dr. Henry: Thank you again.


Ruth: We’re happy to be here.


Dr. Henry: Thank you.




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This podcast is sponsored in part by Lundbeck.

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