What are the best medications for treating migraines in an Emergency Department (ED) setting?

From the Guidelines

The best medications for treating migraines in the Emergency Department include intravenous metoclopramide (10 mg), prochlorperazine (10 mg), and ketorolac (30 mg). These first-line agents are often more effective than opioids and have fewer side effects. Metoclopramide and prochlorperazine work by blocking dopamine receptors, which helps with both nausea and pain, while ketorolac is an NSAID that reduces inflammation and pain.

Key Points to Consider

• For patients who don't respond to these medications, second-line options include intravenous magnesium sulfate (1-2 g), valproate sodium (500-1000 mg), or dexamethasone (10 mg), with the latter being particularly helpful in preventing headache recurrence.
• Sumatriptan (6 mg subcutaneous or 20 mg intranasal) can be effective for patients without cardiovascular contraindications.
• Fluid rehydration with normal saline should be considered for dehydrated patients.
• Antiemetics should be administered before other medications if nausea is present.
• To prevent akathisia with metoclopramide or prochlorperazine, diphenhydramine (25-50 mg IV) can be given simultaneously.
• Patients should be monitored for 30-60 minutes after medication administration to ensure symptom relief before discharge, as recommended by 1 and 1.

Additional Recommendations

• Consider using a nonoral triptan and an antiemetic in people having severe nausea or vomiting, as suggested by 1.
• Counsel patients to begin treatment of migraine headache as soon as possible after its onset, using combination therapy (such as a triptan with an NSAID or acetaminophen) to improve efficacy, as recommended by 1.
• If the episodic migraine occurs frequently or treatment does not provide an adequate response, the addition of preventive medications may be warranted, as noted by 1.

From the Research

Medications for Migraine in an ED Setting

The following medications are considered effective for treating migraines in an Emergency Department (ED) setting:

• Nonsteroidal anti-inflammatory drugs (NSAIDs) and combination analgesics containing acetaminophen, aspirin, and caffeine for mild to moderate migraine 2
• Triptans, such as sumatriptan, for moderate to severe migraine or mild to moderate migraine that has not responded to adequate doses of simple analgesics 2, 3
• Dopamine receptor antagonists, such as metoclopramide, which may be considered as first-line medication for migraine attacks in ED settings 3
• Intravenous antiemetics, with or without intravenous dihydroergotamine, for effective therapies in an ED setting 2, 4
• Corticosteroids, such as dexamethasone, may be a useful adjunct to standard therapy in preventing short-term headache recurrence 2

Medications to Avoid

The following medications should be avoided for acute migraine treatment:

• Opioids, due to their lower efficacy and risk of adverse CNS side effects, habituation, and addiction 2, 4
• Barbiturates, due to their potential for abuse and lack of efficacy in treating migraine 2

New and Emerging Treatments

New classes of acute treatment, including small-molecule calcitonin gene-related peptide receptor antagonists (gepants) and a 5-HT1F receptor agonist (lasmiditan), are expanding available options for migraine treatment 5

• Neuromodulation, such as remote electrical neuromodulation, offers a nonpharmacologic option for acute treatment 5