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

Emergency Room Treatment for Migraine

For most migraine sufferers presenting to the emergency room, first-line therapy should be nonsteroidal anti-inflammatory drugs (NSAIDs), with triptans as second-line therapy for those who don't respond to NSAIDs. 1

First-Line Treatment Options

NSAIDs

• Recommended options:
  • Ibuprofen (400-800mg)
  • Naproxen sodium (500mg)
  • Aspirin
  • Combination of acetaminophen + aspirin + caffeine 1

Note: There is no evidence supporting the use of acetaminophen alone for migraine treatment 1

Administration Considerations

• If significant nausea or vomiting is present, select a non-oral route of administration 1
• Treat nausea with an antiemetic (e.g., metoclopramide, prochlorperazine) even if the patient is not actively vomiting 1
• Antiemetics serve dual purposes:
  1. Treating the nausea component of migraine
  2. Allowing for better absorption of oral medications

Second-Line Treatment: Migraine-Specific Agents

If NSAIDs fail to provide adequate relief, use migraine-specific agents:

Triptans

• Sumatriptan options:
  • Oral: 50mg or 100mg (both doses provide better efficacy than 25mg) 2, 3
  • Subcutaneous: 6mg (most rapid and effective route, with pain relief in 59% of patients vs. 15% with placebo) 4
  • Intranasal: 20mg
  • Rectal: 25mg 4

Important: Subcutaneous administration provides the most rapid pain relief compared to other routes 4

• Other effective triptans:
  • Oral naratriptan
  • Oral rizatriptan
  • Oral zolmitriptan 1

Dihydroergotamine (DHE)

• DHE nasal spray is an effective alternative 1

Treatment Algorithm

1. Start with NSAIDs unless contraindicated
2. Add antiemetic if nausea is present (regardless of vomiting)
3. Switch to triptan if no response to NSAIDs within 2 hours
4. Consider subcutaneous sumatriptan for fastest relief in severe cases
5. Second dose of triptan may be administered if migraine returns after initial improvement (wait at least 2 hours between doses) 2

Dosing Considerations

Sumatriptan Dosing

• Oral: 50mg is optimal for balance of efficacy and tolerability; 100mg may be more effective but has more side effects 2, 3
• Maximum daily dose: 200mg in a 24-hour period 2
• For patients with hepatic impairment: Maximum single dose should not exceed 50mg 2

Safety Considerations

• Contraindications for triptans: History of ischemic heart disease 5
• Common adverse events: Generally mild and short-lived 5
  • Oral sumatriptan: Nausea, vomiting, malaise, fatigue
  • Subcutaneous sumatriptan: Injection site reactions (10-40% of patients)
  • Intranasal sumatriptan: Bitter taste at back of mouth 6
• Serious adverse events: Occur in approximately 0.14% of patients 6
• Warning: Regular use of analgesics may lead to medication overuse headache

Prevention Considerations

While treating the acute attack in the ER, consider evaluating the patient for preventive therapy if they have:

1. Two or more attacks per month with disability lasting 3+ days per month
2. Contraindication to or failure of acute treatments
3. Use of abortive medication more than twice per week
4. Presence of uncommon migraine conditions (hemiplegic migraine, migraine with prolonged aura, migrainous infarction) 1

Medications to Avoid

• Butalbital-containing medications and opioids should be avoided due to risk of dependence and medication overuse headache 7
• Acetaminophen alone lacks evidence for migraine treatment 1