Top 10 Things to Know About Infusions for Headache

1. IV infusions for migraine or headache can be administered in several settings: They can be given in a hospital’s emergency department, inpatient, or outpatient infusion center, in an outpatient private practice headache center, or in the patient’s home (less common and performed by a visiting nursing). Most academic settings offer infusion therapy for refractory headache. 
    
2. Several IV medications have been evaluated for acute and preventive headache treatment: Some of these include Eptinezumab, magnesium, ketorolac, ondansetron, normal saline, metoclopramide, prochlorperazine, valproic acid, dihydroergotamine (DHE), ketamine, levetiracetam, dexamethasone, diphenhydramine, lidocaine and more.
    
3. Many institutions have a “migraine cocktail” that they use for refractory migraine treatment: These usually involve 3 to 4 medications and vary greatly from one institution to another. There is no one standardized “migraine cocktail.”  Variations can include medications, dosage, and frequency.
    
4. Medication combinations can be modified to support each individual patient: Many factors can be taken into consideration such as allergies, age, time the patient has to complete the infusion, side effects of the medications, drug interactions, sedation and driving post infusion, appropriate staff education on patient response to treatments and monitoring (such as rash, nausea, mood changes, cardiac changes and more).
    
5. When prescribing an infusion for a patient you may want to consider: The run time for the infusion of each medication (too many meds can mean several hours for the patient). Past adverse reactions to medications (giving one medication to counteract the negative side effects of the other is not necessarily ideal for the patient – or pleasant). How many infusions a patient is receiving per month (this should not be used as a regular method of treatment too often as overuse of certain meds which can be very dangerous, i.e. steroids, ketorolac, etc.). 
    
6. Outpatient infusion centers can be used as an alternative to a costly ER visit: Staffed by providers knowledgeable in headache care, the team can provide goal directed care avoiding lengthy triage and wait times, unnecessary procedures (neuroimaging with CT, EKG, labs, etc.), inappropriate and dangerous treatments such as narcotics and opioids, and misdiagnosis involving distress for the patient and family (such as an erroneous diagnosis of stroke or anxiety).
    
7. There is a great deal of literature to support IV headache treatment in pediatric and adolescent patients: 10% of pediatric patients can go on to develop refractory headaches. This can cause high levels of disability and lower quality of life. Several studies support IV headache treatment for refractory migraine which has been shown to lead to symptom alleviation and less ER visits.
    
8. A calm environment in your infusion area is part of the recipe for success: No one wants to sit for 1-2 hours in a fluorescent lit very loud room with lots of commotion when they have a migraine even if they are getting an infusion for pain. Create a calm, supportive environment to achieve better outcomes.
    
9. Cost reductions have been found with infusions in outpatient settings: Outpatient infusion centers can help to decrease the cost of acute migraine interventions. The overhead of an outpatient center is lower compared to the hospital. Bulk purchasing of different medicines given the focused specialty treatment (i.e. magnesium, Toradol, DHE, etc.) can lower costs. Staffing support can be modified and limited to certain hours. IV medicines used for other medical disorders can be incorporated to support the centers’ needs and keep the infusion center profitable.  This can include medications used for rheumatologic, neuromuscular, or demyelinating conditions, in addition to Alzheimer’s disease.
    
10. Many private practice neurology groups with infusion centers across the country have combined efforts: There are now opportunities to negotiate bulk purchasing and pricing options for medications with pharmacy companies. As well, these groups work together to compare national reimbursements and negotiate better coverage.
     
11. And finally: If your patient is getting too many emergency infusions maybe it is time to reevaluate their preventive care. IV prevention is an option as well.
     

References of interest:

Strauss, L et al. (2021) Headache infusion centers: A survey on treatments provided, infusion center operations, and barriers to developing new infusion centers, Headache vol 61, Issue 9 pg 1364-1375

Shapiro, H et al. (2022) Development and Evaluation of an Integrated Outpatient Infusion Care Model for the Treatment of Pediatric Headache Pediatric Neurology, ISSN: 0887-8994, Vol: 127, Page: 41-47

Woods, K et al. (2019) Psychosocial and Demographic Characteristics of Children and Adolescents With Headache Presenting for Treatment in a Headache Infusion Center, Headache, vol 59, issue 6 Pages 858-868