What is the appropriate emergency department workup for a patient presenting with a severe migraine headache?

From the Guidelines

The emergency department workup for severe migraine should prioritize a thorough history and physical examination to rule out secondary causes of headache, followed by treatment with NSAIDs, such as ibuprofen or acetaminophen, and consideration of adding a triptan if necessary, as recommended by the American College of Physicians guideline 1. When evaluating a patient with severe migraine in the emergency department, it is essential to start with a comprehensive history and physical examination to identify any potential secondary causes of headache, such as meningitis or subarachnoid hemorrhage. Vital signs, neurological examination, and fundoscopic examination should be performed to assess the patient's overall condition. Some key points to consider in the workup and treatment of severe migraine include:

• Ensuring the patient is using the appropriate dosage of NSAIDs or acetaminophen, and considering increasing the dosage if necessary, without exceeding the recommended maximum daily dose 1
• Adding a triptan to an NSAID or acetaminophen if the patient does not achieve sufficient pain relief, taking into account individual patient preferences and factors such as route of administration and cost 1
• Considering the use of CGRP antagonists-gepants or ergot alkaloid for moderate to severe acute episodic migraine headache in nonpregnant outpatient adults who do not tolerate or have inadequate response to combination therapy of a triptan and an NSAID or acetaminophen 1
• Avoiding the use of opioids or butalbital for the treatment of acute episodic migraine due to the risk of medication overuse headache and dependence 1 In terms of specific treatment options, NSAIDs such as ibuprofen or acetaminophen should be considered as first-line treatment, with the addition of a triptan if necessary, as recommended by the American College of Physicians guideline 1. Additionally, antiemetics and neuroleptics may be used to manage nausea and vomiting, and IV magnesium sulfate, dexamethasone, and valproate sodium may be effective for patients with status migrainosus.

From the Research

Emergency Department Workup for Severe Migraine

• The workup for severe migraine in the emergency department may involve neuroimaging, although the diagnostic yield is low, as found in a study published in 2022 2.
• A study from 2022 also found that treatment of mild migraine was in accordance with current guidelines, but few patients with moderate or severe symptoms received recommended treatment 2.
• Medications commonly prescribed for migraine in the emergency department include paracetamol, nonsteroidal anti-inflammatory drugs, metoclopramide, ondansetron, chlorpromazine, and prochlorperazine 2.

Treatment Options for Severe Migraine

• A randomized open-label study from 2013 compared the efficacy and tolerability of intravenous valproic acid with intramuscular metoclopramide + subcutaneous sumatriptan for prolonged acute migraine, and found that intravenous valproic acid was more effective during the first 2 hours 3.
• Other studies have evaluated the effectiveness of various medications for migraine prophylaxis, including propranolol, timolol, amitriptyline, divalproex, sodium valproate, and topiramate as first-line agents 4, 5, 6.
• The choice of prophylactic medication depends on efficacy, co-morbidity, side effects, availability, and cost, as well as patient-specific factors 5, 6.

Investigation and Management Patterns

• A study from 2022 found that most patients with migraine had previously diagnosed migraine (77.7%), and that neuroimaging was performed in 25.9% of patients, with a very low diagnostic yield or significant findings (0.07%) 2.
• The same study found that treatment of mild migraine was in accordance with current guidelines, but few patients with moderate or severe symptoms received recommended treatment, suggesting a need for improved compliance with existing management best practices 2.