What is the best treatment approach for a patient presenting to the Emergency Department (ED) with a severe migraine?

Migraine Relief in the Emergency Department

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

First-Line IV Treatment Protocol

Administer the combination immediately:

• Metoclopramide 10 mg IV - provides direct analgesic effects through central dopamine receptor antagonism, independent of its antiemetic properties 1
• Ketorolac 30 mg IV (60 mg IM if IV access unavailable for patients <65 years) - delivers rapid onset with approximately 6 hours duration and minimal rebound headache risk 1

This combination is superior to either agent alone and represents the strongest evidence-based approach for severe migraine in the ED setting 1.

Alternative IV Options When First-Line Fails or Is Contraindicated

If metoclopramide is contraindicated (pheochromocytoma, seizure disorder, GI bleeding/obstruction):

• Prochlorperazine 10 mg IV - comparable efficacy to metoclopramide with slightly more favorable side effect profile (21% vs 50% adverse events) 1

If NSAIDs are contraindicated (renal impairment with CrCl <30 mL/min, active GI bleeding, severe heart disease):

• Dihydroergotamine (DHE) IV or intranasal - has good evidence for efficacy and safety as monotherapy 2, 1

For patients with rapid progression to peak intensity or significant vomiting:

• Subcutaneous sumatriptan 6 mg - provides highest efficacy with onset within 15 minutes, achieving pain relief in 70-82% of patients and complete relief in 59% by 2 hours 1

Critical Timing Consideration

Begin treatment as early as possible during the attack to improve efficacy 2, 1. Delayed treatment significantly reduces effectiveness of all migraine medications 1.

Medications to Absolutely Avoid in the ED

Never use opioids (hydromorphone, meperidine) or butalbital-containing compounds for migraine treatment 1, 3. These agents:

• Have questionable efficacy for migraine-specific pain 1
• Lead to dependency and medication-overuse headache 1
• Result in eventual loss of efficacy with chronic use 2
• Should only be reserved for cases where all other evidence-based treatments are contraindicated or have failed, sedation is not a concern, and abuse risk has been addressed 2, 1

Avoid oral ergot alkaloids (Cafergot) - poorly effective with substantial risks including myocardial infarction, vasospastic ischemia, and ergot poisoning with chronic use 1.

Contraindications Requiring Alternative Approach

Ketorolac contraindications:

• Renal impairment (CrCl <30 mL/min) 1
• History of GI bleeding or active peptic ulcer disease 2
• Significant heart disease 1

Metoclopramide/Prochlorperazine contraindications:

• Pheochromocytoma 1
• Seizure disorder 1
• GI obstruction or bleeding 1
• CNS depression (prochlorperazine) 1

Triptan contraindications:

• Ischemic vascular disease or vasospastic coronary disease 4
• Uncontrolled hypertension 4
• Significant cardiovascular disease 1, 4
• Within 24 hours of ergot-type medications 2

Disposition and Follow-Up

Before discharge, address medication-overuse headache prevention:

• Counsel patients to limit all acute migraine medications to no more than 2 days per week to prevent medication-overuse headache 1
• If patients require acute treatment more than twice weekly, preventive therapy is mandatory 1, 5

Initiate preventive therapy discussion if:

• Two or more attacks per month producing disability lasting 3+ days 2, 5
• Using abortive medication more than twice per week 2, 5
• Contraindication to or failure of acute treatments 2, 5

First-line preventive options to discuss:

• Propranolol 80-240 mg/day 5
• Topiramate 50-100 mg/day 5
• Candesartan (particularly if comorbid hypertension) 5

Common Pitfalls to Avoid

Do not:

• Use prednisone or corticosteroids for routine acute migraine - limited evidence supports their use; they are more appropriate for status migrainosus 1
• Perform neuroimaging routinely - indicated only when red flags suggest secondary headache (thunderclap onset, progressive worsening, fever with neck stiffness, new neurological deficits) 1, 6
• Allow patients to establish patterns of frequent opioid use, which creates a vicious cycle of medication-overuse headache 1
• Combine triptans and ergot derivatives within 24 hours due to additive vasoconstrictive effects 1