Emergency Department Migraine Headache Care

Aka: Emergency Department Migraine Headache Care, Migraine Headache Care in the Emergency Department, Status Migrainosus

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II. Indications

  1. Migraine Headache refractory to home care (6-72 hours)
  2. Headache Red Flag (e.g. Thunderclap Headache)

III. Epidemiology

  1. Migraine Headache is the fourth most common presentation to emergency departments in the United States
    1. Burch (2015) Headache 55(10): 21-34 [PubMed]

IV. Causes

  1. See Headache Causes

V. History

  1. See Headache History

VI. Examination

  1. See Headache Examination

VII. Diagnostics

  1. See Headache Diagnostic Testing
  2. See Subarachnoid Hemorrhage for CT Head and Lumbar Puncture protocol

VIII. Precautions

  1. See Headache Red Flags (e.g. Thunderclap Headache, Fever)
  2. Do not miss serious Headache Causes (e.g. Subarachnoid Hemorrhage, Meningitis)
    1. See Acute Secondary Headache
  3. Avoid agents less effective in treating Headache (non-DopamineAntagonist Antiemetics)
    1. Promethazine (Phenergan) 12.5 mg IV
    2. Hydroxyzine
    3. Opioids (e.g. Hydromorphone, Morphine)
    4. ParenteralLidocaine
    5. Octreotide

IX. Preparations: DopamineAntagonist Antiemetics

  1. Precautions
    1. Administer via Parenteral Route (IV preferred or IM)
      1. Oral route is unlikely to be effective with these agents due to their high first-pass metabolism
    2. Extrapyramidal Side Effects (especially Akathisia) occurs in 5-40% of cases when given these Anti-emetics
      1. Administer these agents slowly (e.g. dilute in saline and run over 20 minutes)
        1. Lower risk of Extrapyramidal Side Effects (Akathisia) when slowly infused
        2. Parlak (2007) Postgrad Med 83(984):664-8 +PMID:17916877 [PubMed]
      2. Diphenhydramine (Benadryl)
        1. Guidelines no longer recommended prophylactic use to prevent Extrapyramidal Side Effects
        2. Has not been found effective in reducing Extrapyramidal Side Effects
        3. Consider administering if Akathisia occurs
        4. Friedman (2016) Ann Emerg Med 67(1): 32-9 [PubMed]
  2. Prochlorperazine (Compazine) with IV hydration
    1. Often effective for aborting intractable Headache
    2. Consider with Diphenhydramine 12.5 to 50 mg IV to reduce risk of Akathisia, Dystonia
    3. Adults: 10 mg IV
    4. Child: 0.15 mg/kg IV
  3. Metoclopramide (Reglan) 10 mg IV
    1. Excellent first-line agent for Migraine with Nausea
    2. Optimal dose appears to be 10 mg IV
    3. Colman (2004) BMJ 329(7479): 1369-73 [PubMed]
    4. Friedman (2011) Ann Emerg Med 57(5): 475-82 +PMID:21227540 [PubMed]
  4. Droperidol (Inapsine)
    1. Dose: 1.25 to 5 mg slow IV or IM (typical dose 2.5 mg IV, doses as low as 0.625 may be effective)
    2. FDA black box warning due to QT Prolongation risk
    3. EKG monitoring for single or cummulative doses above 1.25 mg
    4. Olanzapine (Zyprexa) or Haloperidol (Haldol) have been used as alternatives in Migraine Headache

X. Preparations: Serotonin Agonist

  1. Precautions
    1. Do not use if Coronary Artery Disease, Cerebrovascular Accident, Uncontrolled Hypertension
    2. Do not use with MAO Inhibitors, and Exercise caution with other serotonergic agents (e.g. SSRI)
    3. Triptans have high Incidence of side effects with Emergency Department use (30%)
      1. Dizziness
      2. Blurred Vision
      3. Confusion
      4. Chest Pain
  2. Triptans (preferred)
    1. Sumatriptan (Imitrex) intranasal, oral or 6 mg subcutaneous
    2. Zolmitriptan (Zomig) intranasal or oral
  3. Dihydroergotamine Mesylate (DHE, not generally used)
    1. DHE 0.5 to 1 mg IV every 8 hours up to cummulative maximum of 3 mg
    2. Migranal 1 spray in each nostril and may repeat once after 15 minutes
  4. References
    1. Derry (2014) Cochrane Database Syst Rev (5):CD009108 +PMID:24865446 [PubMed]

XI. Preparations: Analgesic or Anti-inflammatory

  1. Ketorolac (Toradol)
    1. Dose: 30 mg IV (60 mg IM)
      1. However, one study on general pain management in ED found maximal effect at only 10 mg IV
      2. Motov (2017) Ann Emerg Med 70(2): 177-84 +PMID: 27993418 [PubMed]
  2. Dexamethasone
    1. Dose: 4 to 10 mg IV or oral
      1. Doses above 10 mg are unlikely to provide added benefit
      2. Studies showed benefit at 4 to 8 mg (dose 4 mg may offer adequate benefit and lower risk)
    2. Hydrocortisone or Methylprednisolone IV could be used as alternative (however Dexamethasone is preferred)
    3. Onset of activity is delayed at least 6 hours from administration
    4. May prevent Headache recurrence in following 48-72 hours
    5. Colman (2008) BMJ 336(7657): 1359-61 +PMID:18541610 [PubMed]
    6. Friedman (2023) Neurology 101(14): e1448-54 +PMID: 37604662 [PubMed]
    7. Mirabaha (2017) Adv J Emerg Med 1(1):e6 +PMID: 31172058 [PubMed]
    8. Singh (2008) Acad Emerg Med 15(12): 1223-33 [PubMed]
  3. Intranasal Lidocaine
    1. Position patient supine with head hyperextended with tilt to 30 degrees
    2. Lidocaine 4%, 0.5 ml of solution dripped into nostril on affected side over 30 seconds
    3. Not recommended in current Migraine Headache guidelines as of 2017
  4. Magnesium
    1. Variable efficacy, but at least one study demonstrates efficacy (compared with Decadron and Reglan)
      1. Shahrami (2015) J Emerg Med 48(1):69-76 +PMID:25278139 [PubMed]
  5. Opioids (avoid if possible)
    1. Still used in 47% of emergency visits, but not recommended in guidelines

XII. Preparations: Other agents that have been used historically

  1. Intravenous Fluids
    1. Most emergency department Headache protocols use Intravenous Fluid bolus
    2. However, no benefit found in Headache relief when combined with Metoclopramide
      1. Balbin (2016) Am J Emerg Med 34(4): 713-6 +PMID:26825817 [PubMed]
  2. Antipsychotics with Analgesic and Antiemetic properties
    1. Haloperidol (Haldol) 5 mg IV (pre-bolus 500 to 1000 cc of IV fluids)
    2. Olanzapine (Zyprexa) 5-10 mg ODT or IM once
    3. Chlorpromazine (Thorazine) 12.5 mg IV q20 min prn x3 (avoid)
  3. Anticonvulsant - Valproic Acid (Depacon)
    1. Depacon 300-1000 mg in 100 cc NS IV over 30 minutes

XIII. Preparations: Status Migrainosus (severe refractory Migraine)

  1. Reconsider Headache Differential Diagnosis
    1. See Organic Headache
    2. See Headache Red Flag
  2. Experimental (preliminary data only)
    1. Propofol (sub-Anesthetic dosing)
      1. Follow same protocols as for Conscious Sedation (but dose is ~25% of those doses)
        1. Obtain Informed Consent
        2. Monitoring as with Conscious Sedation
        3. Observe for 2 hours following administration
      2. Dosing (listed for completeness, experimental only)
        1. Adults: 20-30 mg every 5 minutes to effect (average total dose 100 mg)
        2. Child: 0.5 mg/kg every 5 minutes to effect
      3. Efficacy
        1. Highly effective, resolving Headache in most patients within 30 minutes (and remained awake)
        2. Krusz (2000) Headache 40(3): 224-30 [PubMed]
        3. Soleimanpour (2012) BMC Neurol 12:114 [PubMed]
        4. Sheridan (2012) Pediatr Emerg Care 28(12): 1293-6 [PubMed]
        5. Pietka (2020) Acad Emerg Med 27(2):148-60 [PubMed]
  3. References
    1. Claudius and Mecklar in Majoewsky (2012) EM:RAP 12(10): 11-12

XIV. Management: Regional Anesthesia

  1. Greater Occipital Nerve Block
  2. Sphenopalatine Block

XV. References

  1. Lin (2017) EM:Rap 17(11): 9-10
  2. Diamond (1997) Postgrad Med 101(1):169-79 [PubMed]
  3. Friedman (2017) Ann Emerg Med 69(2): 202-7 [PubMed]
  4. Kabbouche (2001) Pediatrics 107:e62 [PubMed]
  5. Kelly (2000) West J Med 173:189-93 [PubMed]
  6. Newman (1998) Neurol Clin 16(2):285-303 [PubMed]
  7. Orr (2016) Headache 56(6): 911-40 +PMID:27300483 [PubMed]
  8. Vinson (2003) Ann Emerg Med 41:90-7 [PubMed]

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