What is the emergency management for migraine?

Emergency Management of Migraine

For emergency management of migraine, NSAIDs are the first-line therapy, followed by triptans as second-line therapy, with antiemetics as adjuncts for nausea and vomiting. 1, 2

Initial Assessment and Red Flags

• Evaluate for red flags that may indicate secondary headache requiring different management: thunderclap headache, atypical aura, head trauma, progressive headache, fever, neck stiffness, focal neurological symptoms, or onset after age 50 1
• Determine severity of migraine attack to guide appropriate treatment selection 2

Treatment Algorithm

First-Line Treatment (Mild to Moderate Attacks)

• Start with NSAIDs with proven efficacy: aspirin, ibuprofen, naproxen sodium, or combination of acetaminophen plus aspirin plus caffeine 1, 2
• Acetaminophen alone lacks evidence for efficacy in migraine treatment 1, 2
• Administer early in the headache phase for maximum effectiveness 1

Second-Line Treatment (Moderate to Severe Attacks or Inadequate Response to NSAIDs)

• Use triptans: oral sumatriptan (25-100 mg), rizatriptan, zolmitriptan, or subcutaneous sumatriptan 1, 2
• Sumatriptan 50 mg offers the best balance of efficacy and tolerability, while 100 mg may provide greater efficacy but with more adverse events 3, 4
• Consider combining triptans with fast-acting NSAIDs to prevent recurrence 1

For Attacks with Significant Nausea/Vomiting

• Select non-oral routes of administration: subcutaneous sumatriptan or nasal spray formulations 1, 2
• Subcutaneous sumatriptan shows the greatest and most rapid efficacy (pain relief in 59% vs 15% with placebo) but with higher adverse events 5
• Add antiemetics such as metoclopramide or prochlorperazine to treat nausea, even if vomiting is not present 1, 2, 6

Management of Status Migrainosus (Prolonged, Severe Migraine)

• Administer intravenous corticosteroids as the mainstay of treatment 2, 6
• Provide IV fluids for hydration 6
• Give antiemetics concurrently to treat nausea and improve gastric motility 6
• Consider parenteral NSAIDs such as ketorolac for rapid onset of action 6
• For refractory cases, consider IV magnesium sulfate 6

Important Considerations and Cautions

• Advise early use of acute medications for maximum effectiveness 1
• Warn patients that frequent, repeated use of acute medication risks development of medication overuse headache 1, 6
• If a second dose is needed, wait at least 2 hours after the first dose of sumatriptan 3
• Maximum daily dose of sumatriptan is 200 mg in a 24-hour period 3
• Reduce maximum single dose to 50 mg in patients with mild to moderate hepatic impairment 3
• Avoid oral ergot alkaloids, which are poorly effective and potentially toxic 1, 7
• Limit opioid use due to questionable efficacy, adverse effects, and risk of dependency 1, 6

Follow-up Considerations

• Evaluate for preventive therapy if patient experiences frequent attacks (generally ≥2 attacks per month) 1, 6
• Consider prophylactic medications such as propranolol, timolol, amitriptyline, divalproex sodium, or sodium valproate 1