What is the initial treatment for migraine headaches in the emergency room (ER)?

From the Guidelines

The initial treatment for migraine headaches in the emergency room should involve intravenous NSAIDs, such as ketorolac, and antiemetics like metoclopramide or prochlorperazine, to rapidly relieve pain and associated symptoms. According to the study published in the American Family Physician in 2002 1, the management of acute migraine headaches involves the use of NSAIDs, combination analgesics, and migraine-specific drugs. For mild to moderate migraine attacks, NSAIDs (oral) and combination analgesics containing caffeine are recommended. However, in the emergency room setting, intravenous medications are often necessary to provide rapid relief.

Some key points to consider when treating migraine headaches in the emergency room include:

• The use of NSAIDs, such as ketorolac (30mg IV), to reduce inflammation and relieve pain 1
• The administration of antiemetics, like metoclopramide (10mg IV) or prochlorperazine (10mg IV), to address nausea and vomiting, which are common symptoms of migraine headaches 1
• The potential use of triptans, such as sumatriptan (6mg subcutaneous), for patients with severe migraines unresponsive to other treatments, if there are no cardiovascular contraindications 1
• The importance of addressing dehydration with IV fluids, as it can worsen migraine symptoms
• The potential benefits of magnesium sulfate (1-2g IV) and dexamethasone (10mg IV) in certain cases, such as patients with aura or those who are pregnant

It is essential to note that the treatment of migraine headaches in the emergency room should be individualized, taking into account the patient's specific symptoms, medical history, and contraindications. The goal is to provide rapid relief while minimizing side effects and preventing headache recurrence after discharge. As stated in the study 1, the combination of isometheptene, acetaminophen, and dichloralphenazone (Midrin) has been shown to be effective in the treatment of milder migraine headaches, but its use may be limited in the emergency room setting.

From the FDA Drug Label

The efficacy of sumatriptan tablets in the acute treatment of migraine headaches was demonstrated in 3, randomized, double-blind, placebo-controlled trials. The recommended dose of sumatriptan tablets is 25 mg, 50 mg, or 100 mg.

The initial treatment for migraine headaches in the emergency room (ER) is sumatriptan tablets with a recommended dose of 25 mg, 50 mg, or 100 mg 2 2.

• The dose of 50 mg or 100 mg may provide a greater effect than the 25 mg dose.
• A second dose may be administered at least 2 hours after the first dose if the migraine has not resolved.
• The maximum daily dose is 200 mg in a 24-hour period.

From the Research

Initial Treatment for Migraine Headaches in the Emergency Room (ER)

The initial treatment for migraine headaches in the ER involves various pharmacologic agents.

• Nonsteroidal anti-inflammatory drugs (NSAIDs), ergotamines, and analgesics are commonly used to treat acute migraine headaches 3.
• Parenteral ergotamines, antiemetics, NSAIDs, corticosteroids, and sumatriptan can be successfully administered in the office or emergency room setting 3.
• Sumatriptan, a potent and selective agonist at the vascular 5HT1 receptor, is effective in relieving migraine headaches and associated symptoms like nausea and vomiting 4, 5.

Comparison of Treatment Options

• A study comparing the efficacy of 20 mg of IV metoclopramide with 6 mg of subcutaneous sumatriptan for the emergency department treatment of migraine headaches found that both treatments relieved migraine headache pain comparably 6.
• The study suggested that metoclopramide may be the preferable therapy for migraines presenting to the emergency department, with some secondary endpoints indicating better outcomes compared to sumatriptan 6.
• Another study reviewed available evidence pertinent to the treatment of acute migraine in adults in the emergency department setting, including drug classes and agents such as opioids, dopamine receptor antagonists, triptans, nonsteroidal anti-inflammatory drugs, corticosteroids, and sodium valproate 7.

Administration and Dosage

• The recommended dosage of sumatriptan at the onset of migraine symptoms is 100 mg orally or 6 mg subcutaneously 4.
• Sumatriptan must not be given together with vasoconstrictive substances, e.g., ergotamines, or with migraine prophylactics with similar properties, e.g., methysergide 4.
• Sumatriptan should not be given during the migraine aura and is contraindicated in patients with ischemic heart disease, previous myocardial infarction, Prinzmetal (variant) angina, and uncontrolled hypertension 4.