First-Line Emergency Department Treatment for Acute Migraine
For an adult with acute migraine in the ED who has no cardiovascular contraindications, the first-line treatment is intravenous metoclopramide 10 mg plus ketorolac 30 mg, administered together or with metoclopramide given 20–30 minutes before the NSAID to maximize synergistic analgesia. 1
Recommended IV Combination Therapy
Metoclopramide 10 mg IV provides direct analgesic effects through central dopamine receptor antagonism—independent of its antiemetic properties—and enhances absorption of co-administered medications by overcoming gastric stasis. 1
Ketorolac 30 mg IV delivers rapid onset analgesia with approximately six hours of duration and carries minimal risk of rebound headache, making it ideal for severe migraine requiring parenteral therapy. 1, 2
This combination is superior to monotherapy with either agent and represents the strongest evidence-based parenteral regimen for acute migraine in the ED setting. 1
Alternative First-Line Parenteral Options
Prochlorperazine 10 mg IV is equally effective as metoclopramide for headache relief and can be substituted when metoclopramide is contraindicated or unavailable. 1, 3
Subcutaneous sumatriptan 6 mg achieves the highest efficacy among all triptan formulations, with 59% of patients pain-free at 2 hours and onset of action within 15 minutes—making it the preferred route when IV access is unavailable or triptans are needed. 1, 3
Second-Line IV Option When First-Line Fails
Dihydroergotamine (DHE) 0.5–1.0 mg IV has strong evidence for efficacy as monotherapy and can be repeated hourly up to a maximum of 2 mg per day. 1, 4
DHE is contraindicated with concurrent triptan use within 24 hours, uncontrolled hypertension, coronary artery disease, pregnancy, and sepsis. 2
Adjunctive Therapy to Prevent Recurrence
- Dexamethasone 10 mg IV should be added to the acute regimen to prevent headache recurrence within 48–72 hours after ED discharge. 3
Critical Contraindications to Screen For
Metoclopramide is contraindicated in pheochromocytoma, seizure disorders, active GI bleeding, and GI obstruction. 1, 2
Prochlorperazine is contraindicated in CNS depression, concurrent use of adrenergic blockers, and carries risk of QT prolongation—avoid in patients with baseline QTc > 500 ms or history of torsades de pointes. 1, 2
Ketorolac is contraindicated in aspirin/NSAID-induced asthma, renal impairment (CrCl < 30 mL/min), active GI bleeding, pregnancy, and cerebrovascular hemorrhage. 1, 2
Triptans (including subcutaneous sumatriptan) are contraindicated in ischemic heart disease, previous MI, uncontrolled hypertension, cerebrovascular disease, basilar or hemiplegic migraine, and concurrent use of ergotamines within 24 hours. 1, 5
Medications to Absolutely Avoid
Opioids (morphine, hydromorphone, meperidine) should not be used as first-line therapy due to lack of efficacy evidence, high risk of medication-overuse headache, potential for dependence, and inferior outcomes compared to dopamine antagonists and triptans. 1, 3
Butalbital-containing compounds carry high risk of medication-overuse headache and should be reserved only for cases where all other evidence-based treatments are contraindicated. 1
Medication-Overuse Headache Prevention
All acute migraine medications must be limited to ≤ 2 days per week (≤ 10 days per month) to prevent medication-overuse headache, which paradoxically increases headache frequency and can lead to daily headaches. 1, 5
If the patient requires acute treatment more than twice weekly, initiate preventive therapy immediately rather than increasing frequency of acute medications. 1
Dosing Details and Repeat Administration
Ketorolac can be repeated every 15–30 minutes up to a maximum of 120 mg per day, with treatment duration not exceeding 5 days. 2
Metoclopramide should be given 20–30 minutes before or concurrently with ketorolac for optimal synergistic effect. 2
Subcutaneous sumatriptan can be repeated once after 1 hour if headache recurs, with a maximum of two 6 mg doses in 24 hours. 1
Common Pitfalls to Avoid
Do not substitute opioids simply because the patient requests them or reports that "nothing else has worked" without first ensuring adequate trials of dopamine antagonists, triptans, and NSAIDs. 1, 3
Do not delay administration of metoclopramide or prochlorperazine until after the patient vomits—these agents provide direct analgesic benefit independent of their antiemetic effects and should be given early. 1
Never co-administer triptans and DHE within 24 hours of each other due to additive vasoconstrictive effects. 1
Avoid establishing a pattern of frequent ED visits for migraine by ensuring the patient is discharged with a plan for preventive therapy if attacks occur more than twice monthly. 1, 5