Emergency Management of Migraine

Initial Assessment and Treatment

The American College of Physicians and other guideline societies recommend evaluating for red flags that may indicate secondary headache requiring different management: thunderclap headache, atypical aura, head trauma, progressive headache, fever, neck stiffness, focal neurological symptoms, or onset after age 50 2
Determine severity of migraine attack to guide appropriate treatment selection, as recommended by the American Academy of Neurology 3

The American College of Emergency Physicians recommends starting with NSAIDs with proven efficacy: aspirin, ibuprofen, naproxen sodium, or combination of acetaminophen plus aspirin plus caffeine for mild to moderate attacks 1, 3
Administer early in the headache phase for maximum effectiveness, as suggested by the American Headache Society 2
Use triptans: oral sumatriptan (25-100 mg), rizatriptan, zolmitriptan, or subcutaneous sumatriptan for moderate to severe attacks or inadequate response to NSAIDs, as recommended by the American College of Cardiology 1, 3
Consider combining triptans with fast-acting NSAIDs to prevent recurrence, as suggested by the European Neurological Society 2

Administer intravenous corticosteroids as the mainstay of treatment, as recommended by the American Academy of Neurology 3, 4
Provide IV fluids for hydration and give antiemetics concurrently to treat nausea and improve gastric motility, as suggested by the Society of Critical Care Medicine 4
Consider parenteral NSAIDs such as ketorolac for rapid onset of action and IV magnesium sulfate for refractory cases, as recommended by the American College of Emergency Physicians 4

Advise early use of acute medications for maximum effectiveness, as recommended by the American Headache Society 2
Warn patients that frequent, repeated use of acute medication risks development of medication overuse headache, as suggested by the European Neurological Society 2, 4
Limit opioid use due to questionable efficacy, adverse effects, and risk of dependency, as recommended by the American College of Physicians 2, 4

Evaluate for preventive therapy if patient experiences frequent attacks (generally ≥2 attacks per month), as recommended by the American Academy of Neurology 1, 2, 4
Consider prophylactic medications such as propranolol, timolol, amitriptyline, divalproex sodium, or sodium valproate, as suggested by the American College of Physicians 1