What is the recommended initial approach for managing migraines in the emergency room (ER)?

Initial Management of Migraines in the Emergency Room

The recommended initial approach for managing migraines in the emergency room is to use NSAIDs as first-line treatment for most patients, followed by migraine-specific agents (triptans or dihydroergotamine) for those who do not respond to NSAIDs. 1, 2

First-Line Treatment Options

• NSAIDs with proven efficacy include aspirin, ibuprofen, naproxen sodium, and the acetaminophen-aspirin-caffeine combination 1, 3
• Acetaminophen alone is ineffective for migraine treatment 1, 3
• For patients with moderate to severe attacks, consider starting with triptans instead of NSAIDs 2, 3
• When nausea or vomiting is present, select a non-oral route of administration and add an antiemetic drug 1, 2

Second-Line Treatment Options

• Triptans with good evidence for efficacy include orally administered naratriptan, rizatriptan, zolmitriptan, and sumatriptan 1
• Subcutaneous sumatriptan has particularly rapid onset of action (within 1 hour) and is effective in 70-80% of patients 4, 5
• Intranasal sumatriptan and zolmitriptan are effective alternatives when oral administration is difficult due to nausea 6
• Dihydroergotamine (DHE) administered intranasally has good evidence for efficacy and safety 1

Route of Administration Considerations

• For patients with significant nausea or vomiting, use non-oral routes such as subcutaneous, intranasal, or rectal 1, 2
• Intranasal triptans are absorbed rapidly with onset of action as early as 15 minutes 6
• Subcutaneous sumatriptan provides the fastest and most reliable relief but may cause more side effects than oral formulations 4, 5

Antiemetic Options

• Metoclopramide not only treats nausea but also improves gastric motility which may be impaired during migraine attacks 2
• Prochlorperazine can effectively relieve both headache pain and nausea 2
• Antiemetics should be used even when nausea is present without vomiting 2

Important Contraindications and Precautions

• Triptans should not be used in patients with uncontrolled hypertension, basilar or hemiplegic migraine, or those at risk for heart disease 1, 5
• Avoid using triptans during the aura phase of migraine 2, 5
• Limit acute treatments to no more than twice weekly to prevent medication-overuse headache 1, 2
• Avoid oral ergot alkaloids, opioids, and barbiturates due to questionable efficacy and risk of dependency 1

Treatment Algorithm for ER Management

1. Initial Assessment:

   • Determine migraine severity (mild, moderate, severe) 1, 3
   • Assess for presence of nausea/vomiting 1, 2
   • Check for contraindications to specific medications 1, 5

2. For Mild to Moderate Migraine:

   • Start with NSAIDs: ibuprofen 400-800mg, aspirin 900-1000mg, or naproxen sodium 2, 3
   • If inadequate response within 2 hours, escalate to a triptan 3

3. For Moderate to Severe Migraine:

   • Consider starting with a triptan (sumatriptan 50-100mg orally or 6mg subcutaneously) 2, 3, 7
   • For patients who previously failed sumatriptan 50mg, consider using 100mg dose 8

4. For Migraine with Significant Nausea/Vomiting:

   • Use non-oral route: subcutaneous sumatriptan 6mg or intranasal triptan 1, 6
   • Add an antiemetic such as metoclopramide or prochlorperazine 2

5. For Refractory Migraine:

   • Consider combination therapy with a triptan plus NSAID 1
   • Dihydroergotamine intranasal or intravenous may be effective 1
   • Opioids should only be considered if other medications cannot be used and if the risk of abuse has been addressed 1

By following this evidence-based approach to migraine management in the emergency room, clinicians can effectively relieve pain and associated symptoms while minimizing the risk of adverse effects and medication overuse.