What is the initial approach to treating a patient presenting to the emergency department with a migraine headache?

Initial Approach to Treating Migraine Headache in the Emergency Department

For patients presenting with migraine headache in the emergency department, the first-line treatment should be NSAIDs (acetylsalicylic acid, ibuprofen, or diclofenac potassium) with prokinetic antiemetics (metoclopramide or domperidone) as adjuncts for nausea and vomiting, followed by triptans as second-line therapy if NSAIDs are ineffective. 1

Step 1: Rule Out Secondary Headache Causes

Before initiating treatment, it is crucial to evaluate for "red flags" that may indicate a secondary headache:

• Thunderclap headache (suggests subarachnoid hemorrhage) 1
• Atypical aura (may indicate TIA, stroke, epilepsy) 1
• Progressive headache (possible intracranial space-occupying lesion) 1
• Headache onset after age 50 (consider temporal arteritis) 1
• Headache associated with fever, neck stiffness (meningitis) 1
• Focal neurological symptoms or signs 1
• Headache aggravated by postures that raise intracranial pressure 1
• Headache with unexplained weight loss or personality changes 1

Step 2: Acute Treatment Algorithm

First-Line Therapy:

• NSAIDs: Administer acetylsalicylic acid, ibuprofen, or diclofenac potassium 1
  • These medications should be given early in the headache phase for maximum effectiveness 1
  • Ketorolac (Toradol) is a parenteral NSAID option commonly used in emergency settings 1

Adjunct Therapy:

• Prokinetic antiemetics: Metoclopramide or domperidone for patients with nausea/vomiting 1
  • These medications not only treat nausea but may also have independent antimigraine effects 1

Second-Line Therapy:

• Triptans: If NSAIDs are ineffective or contraindicated 1
  • Consider combining triptans with fast-acting NSAIDs to prevent recurrence 1

Third-Line Therapy:

• Ditans and gepants: Consider when first and second-line treatments fail 1

Medications to Avoid:

• Opioids and barbiturates: These have questionable efficacy and high risk of dependency 1, 2
• Oral ergot alkaloids: Poorly effective and potentially toxic 1

Step 3: Supportive Care

• Intravenous fluids: Should be limited to cases of ascertained dehydration 2
• Environment modification: Provide a quiet, dark room when possible 1

Step 4: Refractory Migraine Management

For status migrainosus (migraine lasting >72 hours) or refractory cases:

• Corticosteroids: Consider for preventing recurrence 2
• Anticonvulsants: Divalproex sodium may be effective for refractory cases 3
• Nerve blocks: May be considered in selected cases 3

Step 5: Discharge Planning

• Refer patients to a headache specialist for follow-up care 2
• Educate patients about medication overuse headache risk 1
• Consider preventive therapy for patients with frequent attacks (≥2 days/month) 1

Common Pitfalls to Avoid

• Overuse of neuroimaging: Neuroimaging has very low diagnostic yield (0.07%) in patients with typical migraine presentations and no red flags 4
• Medication overuse: Frequent use of acute medications can lead to medication overuse headache 1
• Inadequate treatment of severe pain: Evidence suggests that therapeutic practices often don't align with guidelines, especially for severe migraine 4
• Missing secondary headache causes: Always evaluate for red flags before assuming primary migraine 1

Despite the high prevalence of migraine presentations in emergency departments, treatment often falls short of guideline recommendations, particularly for moderate to severe cases 4. Following this structured approach can improve outcomes and reduce recurrent ED visits.