What You Need to Know about Migraine in Emergency

Some newly published information is aimed to help patients and help professionals understand how migraine is treated in the emergency department (ER/ED).  The Agency for Healthcare Research and Quality in the USA worked with the University of Alberta Evidence-based Practice Center in Canada to review and publish the information that has been gathering over the past few years.

Treating Severe Migraine Headaches in the Emergency Room

This information is aimed to help patients know what to expect, and to help doctors know what treatments have the best science behind them.  Treatment in emergency is unique, with special challenges.

Here are some of the basics of treatment in emergency:

  • You should especially get to emergency if your headache is very severe, if you have new or different symptoms, if you have a stiff neck or fever, or your headache starts very suddenly (especially if you’re over 50).
  • Most (though not all) medications in the ED are given by a shot or through an intravenously (IV).
  • Although pain is usually a major focus of treatment, your doctor may also need to focus on treating nausea and dehydration.

You may be disappointed with the studies’ use of the terms “migraines” and “migraine headaches”, which does tend to confuse the fact that migraine attacks, often serious ones, can come without severe headache.  And to be fair, this is a focus on treating migraine headaches specifically.  But although it’s understandable that the authors want to simplify things and use language people will recognize, I’m afraid the message will be that every migraine attack involves severe headache.

Recommended Treatments

You can use the links below to read through the material more carefully, but here are some of the treatments considered the best by the authors, based on their review of 71 clinical trials.

Of course, the “best treatment” may not be the best for you, depending on your symptoms and medical history.

Some of the most recommended treatments:

  • sumatriptan
  • neuroleptics (such as chlorpromazine or droperidol)
  • NSAIDs (such as diclofenac or ketorolac)
  • antiemetics (in particular metoclopramide)
  • opioids are useful in some instances, but now rarely used because of side effects and risk of overuse.

One more interesting treatment is dexamethasone (Decadron), which is given in order to keep the pain from returning.  It’s usually given along with another treatment, but because of the risk of side effects it’s not usually used unless the patient is at particular risk of an attack returning over the next few days.

There are other medications which may be used, and often they are used in combination (DHE may be effective in combination with other medications).  But generally the medications above have the best evidence behind them – that means fewer side effects and better results – especially relieving pain and intensity of pain.

In spite of the concerns and cautions mentioned above, this should be a useful resource so that you, as a patient, know more about what to expect and what you should discuss with your doctor.  Doctors, this will give you a quick review of the current science of treatment in the ED and ideas of what you need to discuss with your patients.

For patients:  Treating Severe Migraine Headaches in the Emergency Room
For doctors/clinicians:  Comparative Effectiveness Review Summary Guides for Clinicians

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18 comments… add one
  • Just tired of these headaches

  • Amanda Stevens Nov 22, 2013

    Same here going on 45 days with no break

  • Ja'Nice Long Nov 22, 2013

    I have no luck going to the er for migraines so I just don’t go. I find that they think all I want is pain meds.

    • Michael Miles Sep 14, 2016

      For those of us that can only get relief with opiates, the ED is a particularly bad experience, even if you have a documented history of migraine, they look at you suspiciously as though you’re an addict. Horrible.

  • Does anyone also find their sinus affected with migraine? Also get acne flair ups with migraine.

  • Yes Liz my sinus does, it is horrible, sinus pressure equals Migraines for me plus the weather change also 🙁

  • Megan Horan-Hengel Nov 22, 2013

    After 26 years of living with chronic migraine, and taking SEVEN prescriptions a month, I don’t go to the ER either. All they can do is give me a stronger narc than I already have at home….plus I have to deal with the bright lights, explaining the situation, and the bill afterwards….

  • Brian Quinn Nov 22, 2013

    Have your dentist make you a small splint to wear at bedtime. Many migraines are caused by grinding or clenching in your sleep. Quitting caffeine completely helped reduce mine as well.

  • Megan Horan-Hengel Nov 22, 2013

    I’ve tried both Brian. Neither worked for me. I don’t drink much caffeine at all anymore. Do you still get migraines? For how long have you had them? I’m going on 26 years

  • Brian Quinn Nov 22, 2013

    I’ve had them for over 30 years. I used to get them at least one or twice a week. Now I get about a handful a year.

  • Jannette Netta Dann Nov 22, 2013

    Mine is constant 24/7 for two and a half years , i have Lyme disease and Babesia

  • Cheri Nov 22, 2013

    This is good info for someone with classic migraine. However, Triptans are contraindicated for Hemeplegic or Basilar Type Migraines. The treatments for these are different and most ER departments are not familiar with them.

  • Cheri Patrick Nov 22, 2013

    Great! Now we need one for treating Hemiplegic and Basilar Artery Type Migraines, as Triptans can be deadly.

  • I’ve had my headache 24/7 for 2 1/2 years going to the ER is not always good main medicines don’t work for me and they don’t always want to give you the medicine that you need

  • Marie-Eve Hobeika Nov 23, 2013

    Massage therapy can relieve migraines and even make them disappear definitively! Try it before you fill yourself with dangerous chemicals that will only relieve at the moment but not on a long term basis! I had migraines for 20 years but after 7 months of therapeutic massages, i don’t have migraines anymore (sometimes ii still have small headaches or hangover 😉 but no more real migraines!!!). Give it a try!

  • Has anyone tried Botox?

  • David W David Nov 23, 2013

    I had Botox, like any and all others drugs, did not help me.we all are so different l One med works for many but not everybody . Weather, foods, smells are my gig triggers . They run in my family too..

  • Becky Sep 16, 2016

    I’ve had migraines for 52 years. I don’t bother with the ER anymore either. They have a tendency of leaving you in a room for hours and still send you home in pain. I do get the Botox and it seems to have helped some. I think I get migraines less often but when I do, they seem more intense.

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