IN DHE presents a valuable alternative. In direct comparison to sumatriptan it proves not to work as fast and it is unlikely to challenge sumatriptans dominance in the treatment of acute severe migraine. However, for patients who fail to respond to sumatriptan, IN DHE would be an alternative in the acute severe migraine. IN butorphanol remains useful in a subset of patients particularly refractory to other abortive modalities in whom rapid opiate analgesia is required. The side effect profile was not well characterized in the Diamond report but poor tolerance is often the limiting factor.
Patients find the nausea, drowsiness and dizziness prohibitive for routine use.
A few, however, have discovered benefit for nocturnal migraines after which they can sleep once the pain resolves. IN lidocaine administration is cumbersome. The patient must lie flat for 30 post-treatment minutes, with the head tilted back 45 and rotated 30 toward the affected side. Despite this technical challenge Maizels describes a favorable response but fails to demonstrate how IN lidocaine would fare in severe migraine attacks. Furthermore he does not report on the incidence of nasal numbness and burning which in our experience poses a major obstacle.