Use of Esketamine in the Treatment of Migraine Resistant to Standard Therapy

Aim: This case report aims to describe the management of migraine resistant to standard therapy in the emergency department (ED) using intravenous esketamine, a novel treatment modality and a potent analgesic agent. Case report: A 24-year-old female presented to the ED with a chief complaint of intense headache lasting for 3 hours. She had a history of migraine headaches that were successfully treated with non-steroidal anti-inflammatory drugs (NSAIDs). The neurologic status was without abnormalities. The patient reported a pain intensity of 9/10 on the visual analogue scale (VAS). A peripheral venous cannula was placed. She was administered 10 mg of metoclopramide over 10 minutes intravenously, without a significant improvement in the VAS. After half an hour, she was administered another 10mg of metoclopramide, followed by 100 mg of ketoprofen over 30 minutes intravenously. Her VAS remained at 9/10, therefore a computed tomography (CT) scan of the brain with intravenous contrast was ordered. The laboratory tests were all within reference intervals. The CT scan reported no intracranial pathology. Due to persistent pain with a VAS of 9/10, the patient was administered 0.05 mg/kg of esketamine as an infusion over 30 minutes, followed by an infusion of 12 mg of dexamethasone, after which she reported a decrease in VAS from 9/10 to 2/10. Following symptom resolution and observation without any adverse events noted, the patient was discharged home with detailed return precautions. Conclusion: Esketamine is a potent analgesic which can be used an effective third-line therapy for migraine headache refractory to conventional treatment.