Initial Management of Migraines in the Emergency Room

First-Line Treatment Options

The American Academy of Family Physicians recommends using NSAIDs as first-line treatment for most patients with migraines, followed by migraine-specific agents for those who do not respond to NSAIDs 1, 2, 3
NSAIDs with proven efficacy include aspirin, ibuprofen, naproxen sodium, and the acetaminophen-aspirin-caffeine combination 1, 2, 4
Acetaminophen alone is ineffective for migraine treatment 1, 4

Triptans with good evidence for efficacy include orally administered naratriptan, rizatriptan, zolmitriptan, and sumatriptan 1, 2
Dihydroergotamine administered intranasally has good evidence for efficacy and safety 1, 2

For patients with significant nausea or vomiting, use non-oral routes such as subcutaneous, intranasal, or rectal 2, 3

Metoclopramide not only treats nausea but also improves gastric motility which may be impaired during migraine attacks 3
Prochlorperazine can effectively relieve both headache pain and nausea 3
Antiemetics should be used even when nausea is present without vomiting 3

Triptans should not be used in patients with uncontrolled hypertension, basilar or hemiplegic migraine, or those at risk for heart disease 1, 2
Limit acute treatments to no more than twice weekly to prevent medication-overuse headache 2, 3, 5
Avoid oral ergot alkaloids, opioids, and barbiturates due to questionable efficacy and risk of dependency 6

Determine migraine severity and assess for presence of nausea/vomiting 2, 3, 7
Check for contraindications to specific medications 2
For mild to moderate migraine, start with NSAIDs and escalate to a triptan if inadequate response within 2 hours 3, 4
For moderate to severe migraine, consider starting with a triptan 3, 4
For migraine with significant nausea/vomiting, use non-oral route and add an antiemetic 2, 3
For refractory migraine, consider combination therapy with a triptan plus NSAID or dihydroergotamine intranasal or intravenous 1, 2, 6

Intravenous metoclopramide may be an appropriate choice as monotherapy for acute attacks, particularly in patients with nausea and vomiting 8
Subcutaneous sumatriptan has a very rapid onset of action, making it ideal for emergency settings 8
For refractory migraine, consider intravenous dihydroergotamine (DHE) 0.5-1.0 mg 8, 9
Triptans should not be used in patients with uncontrolled hypertension, basilar or hemiplegic migraine, or those at risk for heart disease 8
Ergotamines are contraindicated with concurrent triptan use, beta blockers, antihypertensives, SSRIs, macrolides, and in patients with coronary artery disease or hypertension 9
Limit acute treatments to no more than twice weekly to prevent medication-overuse headache 8