Pregunta 92. En relación a esta paciente cuál es lacondicts más apropiada?

Your answer Was Incorrect
A 35-year-old woman presents at the emergency department with a 5-day history of a severe headache. She reports having three to four episodes a month for the past 16 years during which time she also has nausea and is sensitive to light and noise. Rizatriptan and naproxen usually provide relief if taken at the onset of pain. The current episode is similar to her usual pattern and started 5 days ago when she was out of town without her medication. Ibuprofen taken at the onset of pain provided no relief. Three days ago, she took three doses of rizatriptan but the headache continued. Vital signs and results of neurologic examination are within normal limits, although her heart rate is 102 beats/min, most likely due to dehydration. After initiating IV fluids, which of the following medications should be administered?
A. IV sodium valproate
B. IV hydromorphone
C. IV methylprednisolone **
D. IV prochlorperazine
E. IV levetiracetam
** = Your answer
According to ICHD-3 beta criteria, the patient is experiencing status migrainosus, which requires IV therapy. Parenteral antiemetics are considered first-line pharmacologic therapy for status migrainosus in the emergency department, with high-quality evidence supporting their use. The strongest data exist for prochlorperazine and metoclopramide.
Hydromorphone and all other opiates generally should be avoided as they may lead to dependence and increase the headache relapse rate, although they typically are first-line agents in most emergency departments in the United States. Recent studies also confirm that prochlorperazine is twice as effective as hydromorphone for treatment of acute migraine in the emergency department.
IV steroids are commonly used in these settings, but data does not support their use in reduction of headache pain. Use of IV antiepileptics, specifically sodium valproate, has some support in open–label studies, but no placebo-controlled studies have evaluated its efficacy in patients with status migrainous.
Rozen TD. Emergency department and inpatient management of status migrainosus and intractable headache. Continuum Lifelong Learning Neurol. 2015;21(4):1004-1017.
Friedman B, Shapiro R. Prochlorperazine twice as effective as opioid hydromorphone for acute migraine in EDs. Presentation at the American Headache Society Annual Scientific Meeting (AHS) 2017. Abstract OR-09. June 10, 2017.

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