What is the initial management for migraine headaches in the emergency department?

Emergency Department Management of Migraine Headaches

First-Line IV Treatment Protocol

For migraine patients presenting to the ED, administer IV metoclopramide 10 mg plus IV ketorolac 30 mg as first-line combination therapy, which provides rapid pain relief while minimizing side effects and risk of rebound headache. 1

Primary Treatment Components

• Metoclopramide 10 mg IV provides both direct analgesic effects through central dopamine receptor antagonism and treats accompanying nausea while enhancing absorption of co-administered medications through its prokinetic effects 1, 2

• Ketorolac 30 mg IV (or 60 mg IM for patients under 65 years) has a relatively rapid onset of action with approximately six hours of duration, making it ideal for severe migraine abortive therapy with minimal risk of rebound headache 1

• Prochlorperazine 10 mg IV is an equally effective alternative to metoclopramide, with comparable efficacy for relieving headache pain and a more favorable side effect profile than chlorpromazine (21% vs 50% adverse events) 1

Critical Timing Consideration

• Begin treatment as early as possible during the attack to improve efficacy, as delayed treatment significantly reduces effectiveness 1, 2

Second-Line Options When First-Line Fails

If patients fail to improve sufficiently after first-line treatment, use IV NSAIDs (ketorolac if not already given), IV acetaminophen, or dihydroergotamine (DHE) as second-line therapy. 3

Evidence-Based Alternatives

• IV acetaminophen or additional IV NSAIDs are reasonable second-line options based on their demonstrated efficacy as first-line treatments 3

• Dihydroergotamine (DHE) has good evidence for efficacy and safety as monotherapy for acute migraine attacks and can be considered when NSAIDs are contraindicated 1

• Greater occipital nerve blocks (GONBs) have been shown to be efficacious for patients who fail first-line medications, though this requires clinician expertise 3

What to Avoid in the ED

Opioids Have No Role

• Opioids, including hydromorphone, should be avoided as they lead to dependency, rebound headaches, eventual loss of efficacy, and patients receiving IV hydromorphone are much less likely to attain acute headache relief 1, 2, 4

• Reserve opioids only for cases where other medications cannot be used, when sedation effects are not a concern, or when the risk for abuse has been addressed 1

Limited or No Evidence

• Ketamine does not provide substantial relief to migraine patients and should not be used 4

• IV fluids show no statistically significant treatment effect on migraine pain and lead to longer ED lengths of stay; administer only to patients with clinical evidence of dehydration 5, 4

• Corticosteroids like prednisone have limited evidence supporting their use in acute migraine treatment and are more appropriate for status migrainosus rather than routine acute headache 1

Important Safety Considerations

Medication-Overuse Headache Prevention

• Limit acute therapy to no more than twice per week to guard against medication-overuse headache, which can result from frequent use of acute medications and lead to daily headaches 1, 2

Contraindications to Monitor

• Ketorolac: Use with caution in patients with renal impairment (creatinine clearance <30 mL/min), history of GI bleeding, or heart disease 1

• Metoclopramide: Contraindicated in patients with pheochromocytoma, seizure disorder, GI bleeding, and GI obstruction 1

• Prochlorperazine: Additional risks of tardive dyskinesia, hypotension, tachycardia, and arrhythmias; contraindicated in CNS depression and use of adrenergic blockers 1

When to Transition to Preventive Therapy

• If patients require ED visits or use acute medications more than 2 days per week, initiate preventive therapy rather than increasing acute medication frequency 2

• Preventive therapy reduces attack frequency and can restore responsiveness to acute treatments 1