From the Guidelines
Migraine headaches in the emergency room are typically treated with a combination of medications to address pain, nausea, and associated symptoms, with first-line treatment often including intravenous non-steroidal anti-inflammatory drugs (NSAIDs) such as ketorolac 30mg IV or antiemetics with analgesic properties like metoclopramide 10mg IV or prochlorperazine 10mg IV, as recommended by the most recent guidelines 1.
Key Considerations
- The choice of treatment should be based on the frequency and severity of attacks, presence and degree of temporary disability, and profile of associated symptoms, such as nausea and vomiting, as well as the patient's history, response, and tolerance for specific medications 1.
- NSAIDs, such as aspirin, ibuprofen, or diclofenac potassium, are recommended as first-line medication for acute migraine treatment 1.
- Triptans, such as sumatriptan, may be administered for severe migraines, and IV magnesium sulfate, dexamethasone, or valproate may be considered in cases where standard treatments fail 1.
- Fluid rehydration with normal saline and placement in a quiet, dark room can also be beneficial in managing migraine symptoms 1.
Treatment Options
- Aspirin-acetaminophen-caffeine is recommended as a first-line treatment for acute migraine 1.
- Gepants, such as ubrogepant and rimegepant, and ditans, such as lasmiditan, are newer options for acute migraine treatment, but their use should be individualized based on patient response and tolerability 1.
- For preventive treatment, beta blockers, topiramate, and CGRP monoclonal antibodies, such as erenumab, fremanezumab, and galcanezumab, are recommended as first-line options 1.
Non-Pharmacologic Therapies
- Aerobic exercise and physical therapy are recommended as adjunctive treatments for migraine and tension-type headache 1.
- Behavioral medicine interventions, such as cognitive behavioral therapy and mindfulness-based therapies, may be beneficial in managing headache symptoms, but the evidence is limited 1.
From the FDA Drug Label
Dihydroergotamine Mesylate Injection is indicated for the acute treatment of migraine headaches with or without aura and the acute treatment of cluster headache episodes. Dihydroergotamine Mesylate Injection, USP is indicated for the acute treatment of migraine headaches with or without aura and the acute treatment of cluster headache episodes.
The dihydroergotamine injection can be used for the acute treatment of migraine headaches.
- It is available in IV and IM forms.
- The sumatriptan tablet is also effective in the acute treatment of migraine headaches 2. However, the most suitable option for treatment in the ER setting would likely be dihydroergotamine due to its administration route, which can be more suitable for an emergency setting 3 or 4.
From the Research
Migraine Headache Treatment in the ER
- Migraine headaches account for approximately 1.2 million emergency department (ED) visits annually 5.
- First-line treatments, including metoclopramide, prochlorperazine, and sumatriptan, fail to provide sufficient relief in up to one-third of treated patients 6.
- For patients who fail to improve after treatment with a first-line medication, it is reasonable to use an intravenous NSAID or intravenous acetaminophen as a second-line treatment 6.
- Greater occipital nerve blocks (GONBs) have been shown to be efficacious as a second-line treatment for migraine in the ED setting 6.
- Dihydroergotamine and valproic acid have some data supporting efficacy as second-line treatments for migraine 6.
- Opioids, except for meperidine, have been shown to be not efficacious in the treatment of migraine in the ED setting 6.
- Propofol and ketamine have been shown to have no role in the treatment of migraine in the ED setting 6.
Treatment Options
- Sumatriptan is a selective agonist at serotonin 5-HT1-like receptors and is an effective treatment for acute migraine attacks 7.
- Metoclopramide has been shown to have pain-relieving effects for migraine and can be considered as a first-line medication for migraine attacks in ED settings 8.
- Acetaminophen and nonsteroidal anti-inflammatory drugs are first-line treatments for mild to moderate migraines, whereas triptans are first-line treatments for moderate to severe migraines 9.
- Antiemetics, ergot alkaloids, and combination analgesics have evidence supporting their effectiveness in the treatment of migraine 9.
Considerations
- The choice of treatment should be individualized based on the pattern and severity of attacks, as well as the patient's medical history and potential adverse effects of the medication 9.
- Taking medication early in an attack and using a stratified treatment approach can help ensure that migraine treatment is cost-effective 9.