What is the recommended treatment for migraine in the Emergency Department (ED)?

Treatment of Migraine in the Emergency Department

For acute migraine treatment in the Emergency Department, intravenous NSAIDs should be used as first-line therapy, followed by intravenous prochlorperazine with diphenhydramine as second-line, and triptans as third-line options. 1, 2

First-Line Treatment Options

NSAIDs

• Recommended as first-line treatment for migraine in the ED 1, 2
• Options include:
  • Ibuprofen 400-800 mg IV
  • Diclofenac potassium IV
  • Ketorolac IV (strongly recommended based on low-level evidence) 3
  • Acetylsalicylic acid (ASA) IV (strongly recommended based on moderate evidence) 3

Second-Line Treatment Options

Dopamine Antagonists

• Prochlorperazine 10 mg IV with diphenhydramine 25 mg IV
  • Strongly recommended based on high-level evidence 3
  • Superior to subcutaneous sumatriptan in ED treatment of migraine 4
  • The addition of diphenhydramine helps prevent akathisia and other extrapyramidal side effects 4, 5

Metoclopramide

• 10-20 mg IV with diphenhydramine
  • Strongly recommended based on moderate-level evidence 3
  • Similar efficacy to prochlorperazine but slightly higher side effect profile 5

Third-Line Treatment Options

Triptans

• Recommended when NSAIDs and dopamine antagonists fail or are contraindicated 1
• Options include:
  • Sumatriptan 6 mg subcutaneous
  • Rizatriptan, zolmitriptan, naratriptan (oral forms)

Important Contraindications for Triptans

• Uncontrolled hypertension
• Basilar or hemiplegic migraine
• Cardiovascular disease or risk factors
• Use of ergotamine-type medications within 24 hours
• Use of MAOIs
• Use of other triptans within 24 hours 1, 2

Adjunctive Treatments

Antiemetics for Nausea/Vomiting

• Metoclopramide or prochlorperazine (which serve dual purpose as both antiemetic and antimigraine)
• Ondansetron may be used but has less evidence for migraine relief 6

IV Fluids

• Consider IV fluid bolus (1L normal saline)
• Note: Limited evidence suggests IV fluids alone may not significantly improve outcomes when combined with standard antimigraine therapy 7

Medications to Avoid in the ED

• Oral ergot alkaloids (poorly effective and potentially toxic) 1
• Opioids and barbiturates (questionable efficacy, adverse effects, dependency risk) 1, 2
• Dexamethasone (strongly recommended against based on moderate evidence) 3
• Haloperidol, trimethobenzamide, granisetron (recommended against based on low evidence) 3

Important Considerations

Red Flags Requiring Further Investigation

• Thunderclap headache (subarachnoid hemorrhage)
• Atypical aura
• Progressive headache
• Headache onset >50 years of age
• Unexplained fever or neck stiffness
• Focal neurological symptoms 1

Monitoring for Side Effects

• Watch for extrapyramidal symptoms with prochlorperazine (dystonia, akathisia)
• Monitor for sedation, especially with antihistamine combinations
• Be aware of potential for QT prolongation with some antiemetics 8

Discharge Planning

• Provide acute medications for home use (NSAIDs as first-line)
• Consider preventive therapy if attacks occur ≥2 times per month with disability for ≥3 days per month 1, 2
• Advise against frequent use of acute medications to prevent medication overuse headache 1
• Consider referral to neurology for refractory cases 2

The evidence strongly supports using a stepwise approach, starting with NSAIDs and progressing to dopamine antagonists and then triptans if needed, while avoiding opioids and barbiturates due to their risk profiles.