There are only a few things I know about the world. Sunrise in the east, sunset in the west. Death and taxes. Jennifer Garner was thinking about migraines.

TL:DR – reglan, without benadryl. Decadron before they’re gone. Also try some other stuff, as long as it’s not opioid. Beware side effects.

I’ve been going over migraine treatment over the last few weeks and hopefully got to most of you.

First things first, I trained under Guru Ben Friedman while in residency @Jacobi_EM.  And…well bromance.

Migraine is the cause of many more than 1 million ED visits per year. Once thought (and still taught) as a vascular phenomenon, it most likely is not. Rather, it’s more likely caused by complex brain stuff that goes wrong, which we probably aren’t smart enough to understand right now. But basically, stuff that shouldn’t hurt, hurts during a migraine, leading to photo/phonophobia, and other consequences of allodynia.

Good news for me and you and the patient. We don’t need any lab tests to diagnose somebody with a migraine. Many would advocate for pregnancy test, although for many meds, even if they happen to be preggers, they have a favorable profile in the pregnant patient. That said, I’m hard pressed to argue effectively against a urine pregnancy test in any appropriately aged female.

There are official criteria for migraine headache from the International Classification of Headache Disorders (below). Which can be hard to get at in the ED during an acute headache, and are probably best left to clinic follow up for evaluation. But if it’s a headache with nausea, vomiting, photophobia, phonophobia, one-sided, and made you come to the ED, there’s a good chance it’s a migraine.

Migraine Headache – Official Criteria:
At least 5 attacks fulfilling criteria B-D
Headache attacks lasting 4-72 Hours
Headache includes ≥2 of the following characteristics:
Unilateral, Pulsating, Moderate-Severe Intensity, Aggravation by or causing avoidance of routine physical activity
At least 1 of: Nausea/Vomiting OR Photophobia/Phonophobia
Not attributed to another disorder

You could use a simple 3 question tool (below) if you like tools.

During the last 3 months, did you have any of the following with your headaches?
Felt nauseated or sick to your stomach when you had a headache.
2. Light bothered you (a lot more than when you did not have headaches)
3. Your headaches limited your ability to work, study, or do what you needed to do for at least 1 day.
Positive Result: ≥2 out of the 3 questions
Sensitivity 81%, Specificity 75% (not evaluated in acute care settings)

There are lot of things we do for headaches (where we are not certain of the cause/type), and somewhat fewer things we do for migraines (where we are certain “enough” of the cause).

Each ED seems to have 3 or 4 cocktails they use for Headache NOS and 1 or 2 for migrainous headaches.


Treatment Options:

Let’s briefly look at effectiveness (in relieving migraine) of some of the more common components of headache cocktails in the ED. 

IVF – Like almost everything we give IVF for, we’re probably wrong. I suppose if your patient has been unable to PO for more than a day, then…well…ok. Better to get them to take PO fluids though.

Ketoralac – Great for headaches generally, so if you have a patient without obvious migraine characteristics, or a mixed picture, 15mg IM/SC ketoralac is reasonable. But it’s not well supported for migraine.

APAP – If they haven’t tried acetaminophen, and it might be a ‘regular’ headache, for goodness sake, give them some. Migraine, not so much.

Nerve blocks/trigger point injections, etc. – Seem cool and you get to do stuff. So if you like to do stuff and nothing else is working, go for it. But as for evidence, well it is probably no worse than IVF and you do that all the time.

Magnesium – 2mg IV. Inconsistent, may even worsen headache.

Hydromorphone/oxycodone/morphine/etc – You may be the cause of all that is wrong in the world. How could you? But you’re not alone, it is (was?) the most commonly prescribed class of medications for ED treatment of migraine.


Metoclopramide (reglan) – Yes, please. 10mg IV in 50cc bag is probably best.
Prochlorperazine (compazine) – Sure. 10mg IV in a bag.
Promethazine (phenergan) – OK. If the nausea is super bad. 25mg IV in a bag.
Haloperidol/droperidol (haldol/inapsine) – Droperidol has a black box warning for Torsades de pointes, so there’s that. But it probably works the best. Haldol is good. It probably is close to droperidol for QT prolongation. 5mg slow IV (50cc bag is good).

All of these medications should make you think of extrapyramidal side effects (e.g. akathisia). You underestimate the frequency of these, by the way. Up to one-third of your patients (10-35% depending on med, route, rate) will feel very distressed by them, and say they “never want that again.” Problem for us is, they often feel better from the headache, go home then feel like they can’t hold still. So unless you go home with them, which I don’t suggest, you should probably warn them about that, and advise Benadryl if it occurs.

Diphenhydramine – 25mg IV (in a bag is best). If you give it for sedation well, go ahead then. As I’ve said many times before, “it is hard to have a headache, or to vomit, if you’re asleep.” But most of the antidopaminergics are good for sleepytime on their own.

Friedman studied metoclopramide with and without diphenhydramine. His work shows you don’t need it with this antidopaminergic. Other meds, haven’t been studied without it yet, so I guess officially you should still give Benadryl with the others.

Triptans (sumatriptan) – Typically seen for well followed chronic migraine patients in the PO formulation. Can also be given SC, 3mg or 6mg. Studies suggest many will feel better in the time it takes pizza to be delivered. Mean time to symptom resolution is 34 minutes. But…you guessed it. Side effects. Frequent chest discomfort, flushing sensation, worsening headache. It’s a tradeoff. There’s a lot to be said for no iv, stick them in a dark room, write your note, see another patient. By the time you are done with that they are ready to go. Works best in patients who take triptans, or in those who have family members that respond to triptans.

Dexamethasone (decadron) – Migraine is a chronic type headache. You can reduce frequency of rebound migraine and ED re-presentation. 10mg IV/IM dexamethasone does a reasonable job in those who don’t have contraindications, like DM, old folks, those prone to the psychosis of steroids.



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Faculty Author: Steve McGuire, DO
Resident Review: Jeffrey Rixe, MD