Status Migrainosus Treatment with Valproate

Introduction to Valproate Therapy

The American Academy of Family Physicians recommends intravenous valproate as an effective abortive treatment for status migrainosus, particularly when first-line therapies fail or are contraindicated 1
The American Academy of Family Physicians suggests that steroid therapy may be preferred and newer evidence suggests lidocaine may offer superior outcomes 1

The American Academy of Neurology and other guideline societies imply that valproate is contraindicated in women of childbearing potential due to teratogenicity, decreased IQ in exposed children, and neurodevelopmental disorders 4, 5
This contraindication greatly limits the utility of valproate in migraine treatment, given the demographic most affected 4

The guideline society recommends considering valproate when steroid therapy is contraindicated or ineffective 1
The American Academy of Neurology suggests that valproate may be used in patients with comorbid seizure disorder requiring dual management, although this is based on a lower level of evidence 2
The guideline society notes that valproate may have significant adverse effects, including hepatotoxicity and pancreatitis risk, and infusion interruptions occur in 25.4% of patients 4, 6

The maximum infusion rate of valproate is 10 mg/kg/min if rapid control is needed, according to the guideline society 3

The guideline society notes that valproate has a higher risk of adverse effects compared to lidocaine (67% vs 3.2%, P<0.001) 6
The American Academy of Neurology suggests that oral valproate is classified as second-line preventive therapy, but only in men due to contraindication in women of childbearing potential 4, 5