Management of Adults With Acute Migraine in the Emergency Department

The American Headache Society Evidence Assessment of Parenteral Pharmacotherapies

Serena L. Orr, MD; Benjamin W. Friedman, MD, MS; Suzanne Christie, MD, FRCPC; Mia T. Minen, MD; Cynthia Bamford, MD; Nancy E. Kelley, MD, PhD; Deborah Tepper, MD


Headache. 2016;56(6):911-940. 

In This Article

Abstract and Introduction


Objective. To provide evidence-based treatment recommendations for adults with acute migraine who require treatment with injectable medication in an emergency department (ED). We addressed two clinically relevant questions: (1) Which injectable medications should be considered first-line treatment for adults who present to an ED with acute migraine? (2) Do parenteral corticosteroids prevent recurrence of migraine in adults discharged from an ED?

Methods. The American Headache Society convened an expert panel of authors who defined a search strategy and then performed a search of Medline, Embase, the Cochrane database and clinical trial registries from inception through 2015. Identified articles were rated using the American Academy of Neurology's risk of bias tool. For each medication, the expert panel determined likelihood of efficacy. Recommendations were created accounting for efficacy, adverse events, availability of alternate therapies, and principles of medication action.

Results/Conclusions. The search identified 68 unique randomized controlled trials utilizing 28 injectable medications. Of these, 19 were rated class 1 (low risk of bias), 21 were rated class 2 (higher risk of bias), and 28 were rated class 3 (highest risk of bias). Metoclopramide, prochlorperazine, and sumatriptan each had multiple class 1 studies supporting acute efficacy, as did dexamethasone for prevention of headache recurrence. All other medications had lower levels of evidence.

Recommendations. Intravenous metoclopramide and prochlorperazine, and subcutaneous sumatriptan should be offered to eligible adults who present to an ED with acute migraine (Should offer—Level B). Dexamethasone should be offered to these patients to prevent recurrence of headache (Should offer—Level B). Because of lack of evidence demonstrating efficacy and concern about sub-acute or long-term sequelae, injectable morphine and hydromorphone are best avoided as first-line therapy (May avoid–Level C).


Background and Justification

Acute migraine causes 1.2 million visits to US emergency departments (ED) annually.[1] More than 20 different parenteral medications and combinations of medications are used to treat migraine in US EDs, including migraine-specific medications such as sumatriptan and dihydroergotamine (DHE), anti-dopaminergics, such as metoclopramide and the neuroleptic prochlorperazine, opioids, corticosteroids, nonsteroidal anti-inflammatory drugs, and anti-histamines such as diphenhydramine and promethazine.[1,2] The causes of this heterogeneity in emergency practice have not been explored systematically but are probably multifactorial and include physician comfort and familiarity with specific medications, concern about short-term side effects, beliefs about efficacy, and response to patient request. The ideal parenteral medication would offer rapid and sustained headache freedom, without short or long-term sequelae, and allow patients to return rapidly to work or usual daily activities. Unfortunately, such a medication does not exist. Published clinical trials demonstrate that fewer than 25% of patients experienced sustained headache freedom after treatment of acute migraine in the ED.[3] Many of the medication classes listed above have been associated with irreversible but uncommon side effects such as ischemic vascular complications with migraine-specific medications, tardive dyskinesia with anti-dopaminergics, avascular osteonecrosis with corticosteroids, gastrointestinal hemorrhage with NSAIDs, and medication dependence with opioids. ED-based clinical trials have only rarely followed patients for a sufficiently long period of time. Few of these studies had adequate power to detect these uncommon downstream sequelae. Given the very large number of migraineurs presenting to US EDs annually, the heterogeneity in current emergency practice, and the frequent use of potentially harmful medications, it is important to know which parenteral medications should be considered first-line therapy.

Clinical Question Statement

The purpose of this guideline is to provide an evidence-based answer to each of the following questions.

  1. Which injectable medications should be considered first-line treatment for adults who present to an ED with acute migraine?

  2. Do parenteral corticosteroids prevent recurrence of migraine in adults discharged from an ED?