From the Guidelines
For the treatment of migraines in the emergency department, the most effective approach involves the use of NSAIDs, triptans, and antiemetics, with the specific choice of medication based on individual patient needs and preferences, as well as consideration of potential contraindications and side effects 1. When managing migraines in the emergency setting, it's crucial to consider the severity of the migraine and the patient's medical history.
- For mild episodic migraine headache, consider treating with an NSAID, acetaminophen, or the combination of an NSAID and acetaminophen, ensuring the dosage is appropriate and not exceeding the recommended maximum daily dose 1.
- In cases where patients do not achieve sufficient pain relief with NSAIDs or acetaminophen, adding a triptan to the treatment regimen can be effective, or using a triptan with acetaminophen if NSAIDs are contraindicated or not tolerated 1.
- The choice of a specific NSAID (such as aspirin, celecoxib, diclofenac, ibuprofen, or naproxen) or triptan (like almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, or zolmitriptan) should be based on individualized decision making, taking into account patient preferences regarding factors such as route of administration and cost 1.
- For patients with severe nausea or vomiting, consider using a nonoral triptan and an antiemetic, and avoid the use of opioids or butalbital due to the risk of medication overuse headache and dependence 1.
- In moderate to severe acute episodic migraine headache, CGRP antagonists-gepants (rimegepant, ubrogepant, or zavegepant) or ergot alkaloid (dihydroergotamine) may be considered for nonpregnant outpatient adults who do not tolerate or have inadequate response to combination therapy of a triptan and an NSAID or acetaminophen 1.
- Additionally, lasmiditan, a ditan, can be considered for the treatment of moderate to severe acute episodic migraine headache in nonpregnant outpatient adults who do not tolerate or have inadequate response to all other pharmacologic treatments included in the guideline 1.
From the FDA Drug Label
Sumatriptan tablets are contraindicated in patients with Wolff-Parkinson-White syndrome or arrhythmias associated with other cardiac accessory conduction pathway disorders. The use of sumatriptan tablets is contraindicated in patients with CAD and those with Prinzmetal’s variant angina. Cerebral hemorrhage, subarachnoid hemorrhage, and stroke have occurred in patients treated with 5-HT1 agonists, and some have resulted in fatalities Sumatriptan tablets are contraindicated in patients with a history of stroke or TIA. Sumatriptan may cause non-coronary vasospastic reactions, such as peripheral vascular ischemia, gastrointestinal vascular ischemia and infarction Serotonin syndrome may occur with sumatriptan tablets, particularly during co-administration with selective serotonin reuptake inhibitors (SSRIs), serotonin norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs), and MAO inhibitors
Migraine treatment in the emergency department should be approached with caution.
- Contraindications for sumatriptan include CAD, Prinzmetal’s variant angina, history of stroke or TIA, and uncontrolled hypertension.
- Potential risks include cerebrovascular events, non-coronary vasospastic reactions, serotonin syndrome, and anaphylactic reactions.
- Given the potential risks and contraindications, sumatriptan should be used with caution in the emergency department, and only after careful evaluation of the patient's medical history and current condition 2 3.
From the Research
Migraine Treatment in Emergency Department
- Migraine is a common reason for visits to the emergency room, with millions of patients presenting to US emergency departments (ED) annually for treatment 4.
- First-line treatments, including metoclopramide, prochlorperazine, and sumatriptan, fail to provide sufficient relief in up to one-third of treated patients 4.
- For patients who fail to improve after treatment with a first-line medication, it is reasonable to use an intravenous NSAID or intravenous acetaminophen as second-line therapy 4.
- Greater occipital nerve blocks (GONBs) have also been shown to be efficacious as second-line therapy for migraine in the ED setting 4.
Medications for Migraine Treatment
- Metoclopramide, prochlorperazine, and sumatriptan are recommended as first-line treatments for acute migraine in the ED setting 5.
- Dexamethasone is recommended to prevent recurrence of headache in adults discharged from an ED 5.
- Injectable morphine and hydromorphone are best avoided as first-line therapy due to lack of evidence demonstrating efficacy and concern about sub-acute or long-term sequelae 5.
- Dihydroergotamine and valproic acid have some data supporting efficacy as second-line therapy for migraine in the ED setting 4.
Clinical Trials and Guidelines
- A single-center, open-label, cluster-randomized controlled non-inferiority trial compared metoclopramide and sumatriptan for migraine treatment in the ED, with results suggesting metoclopramide may be non-inferior to sumatriptan 6.
- The American Headache Society has published guidelines for the management of adults with acute migraine in the ED, including recommendations for first-line and second-line treatments 5.
- An updated guideline is currently in development, which will include a systematic review and meta-analysis of parenteral pharmacotherapies for migraine treatment in the ED setting 7.