What is the initial treatment for migraine at urgent care?

Initial Treatment for Migraine at Urgent Care

For patients presenting to urgent care with acute migraine, start with 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

First-Line IV Treatment Protocol

The optimal "migraine cocktail" consists of:

• Ketorolac 30-60 mg IV/IM (primary analgesic with rapid onset and 6-hour duration) 1
• Metoclopramide 10 mg IV (provides both antiemetic effects and direct migraine analgesia through dopamine receptor antagonism) 1, 2
• Prochlorperazine 10 mg IV can substitute for metoclopramide with comparable efficacy 3, 1

This combination addresses both pain and nausea while avoiding opioids and their associated risks of dependency and medication-overuse headache 3, 1.

Dosing Adjustments

• For patients ≥65 years or with renal impairment, reduce ketorolac dose 1
• Ketorolac is contraindicated in patients with renal impairment (CrCl <30 mL/min), active GI bleeding, or aspirin/NSAID-induced asthma 1
• Metoclopramide is contraindicated in pheochromocytoma, seizure disorder, GI bleeding, and GI obstruction 3

Second-Line Options for Refractory Cases

If first-line therapy fails after 1-2 hours:

• Subcutaneous sumatriptan 6 mg provides the highest efficacy (70-82% pain relief within 15 minutes, 59% complete pain relief by 2 hours) with fastest onset among all migraine-specific medications 1, 4, 5
• IV dihydroergotamine (DHE) 0.5-1.0 mg for refractory migraine 3, 2

Subcutaneous sumatriptan should not be given to patients with ischemic heart disease, previous MI, uncontrolled hypertension, or significant cardiovascular disease 1, 6.

Oral Therapy for Mild-Moderate Cases

For patients who can tolerate oral medications and have mild-moderate symptoms:

• Sumatriptan 50-100 mg orally (50 mg offers best efficacy-to-tolerability ratio, though 100 mg provides greater efficacy for some patients) 4, 7
• Aspirin-acetaminophen-caffeine combination has strong evidence with NNT of 9 for pain freedom at 2 hours 3
• NSAIDs alone (ibuprofen, naproxen sodium 500-825 mg) for first-line treatment 3, 1

Critical Timing Considerations

• Treat early when pain is still mild - triptans are most effective when administered during the mild-pain phase, not during aura 3
• If migraine has not resolved by 2 hours after oral sumatriptan, a second dose may be given at least 2 hours after the first dose, with maximum daily dose of 200 mg 4
• For IV therapy, reassess at 1-2 hours and consider escalation if inadequate response 1, 2

Medications to Avoid

Never use in urgent care migraine treatment:

• Opioids (hydromorphone, oxycodone) - questionable efficacy, high risk of dependency and medication-overuse headache 3, 1
• Oral ergot alkaloids - poorly effective and potentially toxic 3
• Barbiturates - considerable adverse effects and dependency risk 3

Prevention of Medication-Overuse Headache

• Limit acute treatment to no more than twice weekly to prevent medication-overuse headache, which develops from frequent use and leads to increasing headache frequency 3, 1, 2
• Patients requiring acute treatment more than 2 days per week should be transitioned to preventive therapy 3

Common Pitfalls to Avoid

Do not restrict metoclopramide only to vomiting patients - nausea itself is one of the most disabling migraine symptoms and warrants treatment even without vomiting 1. Metoclopramide also provides direct analgesic effects through central dopamine receptor antagonism and improves gastric motility, enhancing absorption of co-administered medications 1, 2.

Do not use triptans during aura phase - no evidence supports triptan use during aura, and they should be reserved for the headache phase 3.

Screen for cardiovascular contraindications before administering triptans or ergotamines, particularly in patients with uncontrolled hypertension, coronary artery disease, or previous MI 3, 2, 6.