Migraine in the ER: American Headache Society’s Treatment Guideline

Migraine in the ER: American Headache Society’s Treatment Guideline

Written by Kerrie Smyres on 30th Jun 2016

No one wants to go to the ER for a migraine attack, but sometimes there's no choice. The lights, noise, and smells of the ER add to migraine symptoms, but that’s minor compared to the possibility of having to fight for treatment. Patients are just looking for relief, but often feel like they’re treated as if they’re drug-seeking in an attempt to get opioids. Yet the treatments recommended by headache specialists don’t include drugs that have any associated “high.” The American Headache Society has issued new guidelines to attempt to bridge the disconnect between patients and emergency room staff.

The first time a patient goes to the ER for a migraine attack that requires injectable medication, the guidelines say they should be given an Imitrex (sumatriptan) injection and IV Reglan (metoclopramide) and Compazine (prochlorperazine). Patients should also be offered a prescription of the steroid dexamethasone to ward off migraine recurrence. Experts who created the guidelines recommend avoiding injectable morphine and Dilaudid (hydromorphone) as a first-line treatment to prevent worsening of migraine in the future.

Knowing that those drugs may not work for every patient, the panel of experts who developed the list also created alternate lists of drugs. The medications an ER chooses will depend on each patient’s needs. If your doctor has specific medications they believe would be best for you to have in the ER, ask for a letter outlining the recommendations. Be sure to take the letter with you to the ER. Not all ER providers follow your doctor’s recommendations, but having the letter increases the likelihood they will.

The American Headache Society issued these guidelines because emergency departments across the country vary widely in the medications they use to treat migraine. Study author Benjamin W. Friedman, M.D., said that “there are probably 20 different combinations of parenteral medications used to treat acute migraine, and we know that some are probably suboptimal.” The goal of standardizing patient care in the ER is to help the most patients find relief without causing future problems, like medication overuse headache.

The panel of experts developed these guidelines based on a comprehensive review of studies of emergency treatment for migraine. They identified 68 trials using 28 injectable medications; five of the 68 trials also studied steroids for the prevention of migraine recurrence following ER discharge. They assessed the risks associated with each medication and their known efficacy for migraine. The recommended medications all had high levels of evidence.


Anderson, P. (2016, Jun 17). New AHS Consensus on Emergency Migraine Management. Medscape. Retrieved on Jun 17, 2016 from http://www.medscape.com/viewarticle/864989.

Orr, S. L.; Friedman, B. W.; Christie, S.; Minen, M. T.; Bamford, C.; Kelley, N. E.; Tepper, D. (2016). Management of Adults With Acute Migraine in the Emergency Department: The American Headache Society Evidence Assessment of Parenteral Pharmacotherapies. Headache: The Journal of Head and Face Pain 56.6 (2016): 911-940.

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