What are the recommended treatments for acute migraine in the Emergency Department (ED)?

Recommended Treatments for Acute Migraine in the Emergency Department

First-line treatment for acute migraine in the Emergency Department should include combination therapy with NSAIDs (particularly IV ketorolac) and anti-dopaminergic agents (metoclopramide or prochlorperazine), which provide effective pain relief while minimizing side effects and risk of rebound headache. 1

First-Line Parenteral Treatment Options

• IV ketorolac (30mg) is the preferred NSAID with rapid onset of action and approximately six hours of duration, making it ideal for severe migraine abortive therapy with minimal risk of rebound headache 1
• IV metoclopramide (10mg) is effective not only for treating accompanying nausea but also provides synergistic analgesia for migraine pain 1
• IV prochlorperazine (10mg) effectively relieves headache pain and has been shown to be comparable to metoclopramide in efficacy 1
• Combination therapy (such as ketorolac plus metoclopramide) is more effective than monotherapy and should be initiated early in the attack 2

Second-Line Treatment Options

• Dihydroergotamine (DHE) has good evidence for efficacy and safety as monotherapy for acute migraine attacks, particularly when first-line treatments fail 1, 2
• Triptans (serotonin1B/1D agonists) can be considered for moderate to severe attacks not responding to first-line therapy, but require caution in patients with cardiovascular risk factors 2, 3
• Non-oral routes of administration (subcutaneous, intranasal) should be used when significant nausea or vomiting is present 2

Special Considerations for Administration

• For patients with severe nausea or vomiting, use non-oral routes of administration (IV, subcutaneous, or intranasal formulations) 2, 1
• Treatment should begin as early as possible during the attack to improve efficacy 2
• Antiemetics should be administered alongside analgesics when nausea is a significant component 2

Medications to Strictly Avoid

• Opioids (including hydromorphone) should not be used for migraine treatment as they can lead to dependency, rebound headaches, and have limited evidence supporting efficacy 2, 1, 4
• Butalbital-containing compounds should be avoided due to risk of medication overuse headache and limited evidence of efficacy 2
• IV fluids alone do not improve pain outcomes in migraine patients and should only be administered to those with clinical evidence of dehydration 4, 5

Treatment Algorithm

1. Initial approach: IV ketorolac 30mg + IV metoclopramide 10mg or prochlorperazine 10mg 1
2. If inadequate response after 30-60 minutes: Consider IV dihydroergotamine 1mg 2, 1
3. For persistent symptoms: Consider parenteral triptan (subcutaneous sumatriptan) if no cardiovascular contraindications exist 2, 3
4. For status migrainosus: Consider adding dexamethasone to prevent short-term headache recurrence 6

Important Cautions and Contraindications

• Triptans should be avoided in patients with uncontrolled hypertension, coronary artery disease, or hemiplegic migraine 3
• Metoclopramide and prochlorperazine may cause extrapyramidal symptoms; consider administering with diphenhydramine to reduce this risk 1
• Monitor for medication overuse headache, which can develop with frequent use of acute medications (more than twice weekly) 2
• Patients with Parkinson's disease should avoid dopamine antagonist antiemetics (metoclopramide, prochlorperazine) as they may worsen parkinsonian symptoms 7

Prevention of Recurrence

• Consider preventive therapy if acute attacks occur frequently (≥2 per month) or cause significant disability 2, 7
• Counsel patients about lifestyle modifications, including hydration, regular meals, sufficient sleep, regular physical activity, and stress management 2
• Limit acute medication use to no more than twice weekly to prevent medication-overuse headache 2

This evidence-based approach to acute migraine management in the ED prioritizes effective pain relief while minimizing side effects and the risk of medication overuse headache, which can significantly impact patients' quality of life and long-term outcomes.