What are the treatment options for migraine headaches in the Emergency Department (ED)?

From the Guidelines

For migraine treatment in the Emergency Department (ED), the most effective approach is to start with a combination of an NSAID, such as ketorolac 30 mg IV, and an antiemetic, such as metoclopramide 10 mg IV, as first-line therapy, as recommended by the American College of Physicians 1. This approach helps to address both the pain and nausea associated with migraine headaches.

• The choice of a specific NSAID should be based on individualized decision making, taking into consideration patient preferences and factors such as route of administration and cost 1.
• If the initial approach fails, consider adding a triptan, such as sumatriptan 6 mg subcutaneously, for patients without cardiovascular contraindications.
• For refractory cases, consider alternative options such as IV prochlorperazine, IV valproate, or IV magnesium sulfate.
• It is also important to consider the use of preventive medications for patients with frequent or severe migraine attacks, as well as to educate patients on the importance of early treatment and the potential risks of medication overuse headache 1.
• Opioids should be avoided as they can worsen migraine through medication overuse headache, and fluid rehydration with normal saline is beneficial for patients with signs of dehydration.
• The goal of treatment is to provide rapid pain relief, address associated symptoms, and prevent headache recurrence after discharge, while also considering the individual patient's needs and preferences.

From the FDA Drug Label

Six of these 8 patients had ECG changes consistent with transient ischemia, but without accompanying clinical symptoms or signs. Serious cardiovascular events, some resulting in death, have been reported in association with the use of IMITREX Injection or IMITREX Tablets Cardiac events that have been observed to have onset within 1 hour of sumatriptan administration include: coronary artery vasospasm, transient ischemia, myocardial infarction, ventricular tachycardia and ventricular fibrillation, cardiac arrest, and death. Sumatriptan is contraindicated in patients with uncontrolled hypertension (see CONTRAINDICATIONS) Sumatriptan should be administered with caution to patients with controlled hypertension as transient increases in blood pressure and peripheral vascular resistance have been observed in a small proportion of patients

Migraine treatment in the ED with sumatriptan (IM) should be approached with caution. The drug label reports serious cardiovascular events, including death, associated with sumatriptan use 2. These events can occur within 1 hour of administration. Additionally, sumatriptan is contraindicated in patients with uncontrolled hypertension and should be used with caution in patients with controlled hypertension.

• Key considerations:
  • Cardiovascular events
  • Uncontrolled hypertension
  • Controlled hypertension
  • Concomitant drug use It is essential to carefully evaluate patients before administering sumatriptan in the ED, considering their medical history and current condition to minimize potential risks 2.

From the Research

Migraine Treatment in the Emergency Department

• The treatment of migraine in the emergency department (ED) involves various pharmacologic therapies, with the goal of providing adequate pain relief and minimizing adverse reactions 3, 4, 5.
• A study comparing intravenous haloperidol and metoclopramide for acute migraine therapy in the ED found that both treatments were effective, but haloperidol resulted in less frequent need for rescue medications 3.
• Another study compared the efficacy of IV valproate, metoclopramide, and ketorolac for acute migraine, and found that metoclopramide demonstrated superiority to ketorolac on several endpoints, while valproate was less efficacious than either metoclopramide or ketorolac 4.
• A review of current literature on the emergent management of primary headache found that intravenous fluid hydration does not improve pain outcomes and leads to longer ED lengths of stay, and that opioids should be avoided in migraine treatment 6.
• The American Headache Society has proposed an updated guideline for the acute treatment of adults with migraine in the ED, which will provide clinical recommendations based on a systematic review and meta-analysis of parenteral pharmacotherapies 7.
• A systematic review and Bayesian network meta-analysis found that chlorpromazine IV/IM was most likely to be superior for adequate pain relief at 2 hours, while metoclopramide IV-ibuprofen IV was most likely to be superior for not needing rescue drug at 2 hours, and dexamethasone IV was most likely to be superior for not causing adverse reaction 5.

Pharmacologic Therapies for Migraine

• The following pharmacologic therapies have been studied for migraine treatment in the ED:
  • Haloperidol: effective for acute migraine therapy, with less frequent need for rescue medications 3.
  • Metoclopramide: effective for acute migraine therapy, with superiority to ketorolac on several endpoints 4.
  • Valproate: less efficacious than metoclopramide or ketorolac for acute migraine 4.
  • Ketorolac: possibly among the least effective as a single agent for adequate pain relief 5.
  • Chlorpromazine: most likely to be superior for adequate pain relief at 2 hours 5.
  • Dexamethasone: most likely to be superior for not causing adverse reaction 5.
  • Ibuprofen: definitely among the least effective for adequate pain relief 5.