Guidelines for First-Line Treatment for Acute Migraine in the Emergency Department

New guidelines for treatment of migraine in the ED seek to reduce opioid prescription.

Of the 1.2 million people who present to the emergency department (ED) each year for migraine treatment, more than half are treated with opioids despite known risks and recommendations to the contrary, according to a study published in 2015 in Cephalgia.1

There is also significant variation in the types of medications used, which prompted the American Headache Society to convene an expert panel to review the evidence and determine which medications should be considered first-line treatment for acute migraine in adults in the ED.2

The resulting treatment guidelines, published in the June 2016 issue of Headache: The Journal of Head and Face Pain “were needed because studies have shown that there are over 25 different medications that are sometimes used to treat migraine in the ED, yet some of them don’t have good evidence-based data for effectiveness,” co-author Mia T. Minen, MD, MPH, assistant professor of neurology and Director of Headache Services at NYU Langone Medical Center in New York City, told Neurology Advisor.

The range of medications used includes migraine-specific drugs, anti-dopaminergics, opioids, corticosteroids, nonsteroidal anti-inflammatory drugs, and antihistamines. “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 authors wrote. Other research shows that less than 25% of ED treatments for acute migraine led to sustained relief, and many have been linked with uncommon but serious adverse effects, highlighting the need for first-line treatment recommendations.

The panel’s search included randomized trials that compared an injectable medication to an active control or placebo, and the definition of headache used in the studies had to meet International Classification of Headache Disorder migraine criteria and relevant studies had to have assessed outcomes within 1 week of discharge in order to be included in the review. The authors further sought to determine whether parenteral corticosteroids prevent migraine recurrence after ED discharge.

A total of 68 studies involving 28 different medications were ultimately included in the review. The quality of each was rated according to the American Academy of Neurology’s risk of bias tool: class 1 for low risk; class 2 for higher risk; and class 3 for highest risk. With this tool, studies are scored according to factors like clarity of eligibility criteria, concealed allocation, and accounting for discrepancies in baseline characteristics.

The panel’s recommendations accounted for “efficacy, adverse events, availability of alternate therapies, and principles of medication action,” they wrote. Based on numerous class 1 studies supporting efficacy, they recommend metoclopramide, prochlorperazine, and sumatriptan as first-line treatment options for acute migraine in the ED, as well asdexamethasone to prevent recurrence. “Metoclopramide and prochlorperazine are also used for nausea so ED physicians should have some comfort using these medications. Sumatriptan is important because it is a medication that patients can be prescribed on discharge from the ED,” Dr Minen noted. The remaining medications reviewed had inadequate evidence, and injectable morphine and hydromorphone should also be avoided as first-line treatment because of concern regarding adverse effects. The authors do not expect that their recommendations will guide every treatment choice for migraine in the ED, and they acknowledge that factors such as a patient’s medication history and risk of adverse events must also be considered.

“Future research should continue to track migraine treatments in the ED, and importantly, determine the most effective treatments to prevent migraine recurrence,” Dr Minen said. “There should also be evaluation of what other types of evidence-based migraine treatments might be offered in the emergency department, including non pharmacologic treatment and preventive medication,” she concluded.


1. Friedman BW, West J, Vinson DR, Minen MT, Restivo A, Gallagher EJ. Current management of migraine in US emergency departments: an analysis of the National Hospital Ambulatory Medical Care Survey. Cephalgia. 2015; 35(4):301-9.

2. Orr SL, Friedman BW, Christie S, Minen MT, Bamford C, Kelley NE, Tepper D. Management of Adults With Acute Migraine in the Emergency Department: The American Headache Society Evidence Assessment of Parenteral Pharmacotherapies. 2016. Headache. 2016; 56:911–940.


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This article originally appeared on Neurology Advisor