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This tool is educational and informational. It does not replace clinical judgment. Verify acute migraine treatment selection, contraindication screening, and evidence grading against the cited source before acting.
Not prospectively validated. No clinical tool replaces bedside assessment.
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Tarvinder Singh, MD -- Vascular Neurologist. March 2026.
Migraine Management in ED
Narrows treatments by safety constraints, severity, and comorbidities. Shows what is in, what is out, and what to enter next. Grounded in AHS 2025.
Evidence level key (AHS grading)
Level A -- Established as effective.
Level B -- Probably effective.
Level C -- Possibly effective.
Level U -- Insufficient evidence.
Step 1: Quick Intake
Pain, timing, and burden signal
Pain severity
Severe pain favors fast-onset parenteral options.
Nausea severity
Severe nausea favors antiemetics and non-oral routes.
Attack duration
<6 hours matters for early-window evidence.
Migraine days / month
Use when preventive eligibility or emerging evidence matters.
Step 2: Safety and Constraints
Step 3: Already Tried This Visit
Failed or poorly tolerated medications during this visit are deprioritized.
At a glance
Start with pain severity and nausea. Safety flags and prior failures narrow the field further.
Next
Pain severity is the highest-impact first input.
Evidence
Prochlorperazine IV
Must offerOften considered interchangeable with metoclopramide. Some evidence suggests slightly better headache relief but more sedation.
Metoclopramide IV
Should offerInfuse over 15 minutes to reduce akathisia risk. Akathisia is the main limiting side effect.
Ketorolac IV
Should offer15 mg is as effective as 30 mg for acute migraine with fewer side effects. Consider 15 mg as default.
Sumatriptan SC
Should offerFastest onset of any triptan formulation (~10 minutes). Reserve for patients without cardiovascular risk factors.
Prochlorperazine IV
Dopamine antagonist (phenothiazine)
Prochlorperazine 10 mg IV
Often considered interchangeable with metoclopramide. Some evidence suggests slightly better headache relief but more sedation.
More bedside detail
Cautions: Monitor for akathisia Diphenhydramine 25 mg IV may be considered for akathisia prophylaxis (not strongly recommended per current guidelines) May cause hypotension — administer with IV fluids
Administration: Give IV push slowly over 3–5 minutes.
AHS 2025 ED GuidelinesMetoclopramide IV
Dopamine antagonist (antiemetic)
Metoclopramide 10–20 mg IV
Infuse over 15 minutes to reduce akathisia risk. Akathisia is the main limiting side effect.
More bedside detail
Cautions: Monitor for akathisia — most common reason patients refuse repeat dosing Diphenhydramine 25 mg IV may be considered for akathisia prophylaxis (not strongly recommended per current guidelines) Avoid in patients with pheochromocytoma
Administration: Infuse metoclopramide over 15 minutes. If akathisia prophylaxis desired, diphenhydramine 25 mg IV can be given concurrently.
AHS 2025 ED GuidelinesKetorolac IV
NSAID
Ketorolac 15–30 mg IV
15 mg is as effective as 30 mg for acute migraine with fewer side effects. Consider 15 mg as default.
More bedside detail
Cautions: GI bleeding risk — use caution in patients with peptic ulcer history Avoid if on anticoagulation
Administration: IV push over 15–30 seconds. Can also be given IM if no IV access.
AHS 2025 ED GuidelinesSumatriptan SC
Triptan (5-HT1B/1D agonist)
Sumatriptan 6 mg SC
Fastest onset of any triptan formulation (~10 minutes). Reserve for patients without cardiovascular risk factors.
More bedside detail
Cautions: Chest tightness (triptan sensation) is common and benign — distinguish from true ischemia Contraindicated with MAOIs
Administration: Subcutaneous injection into upper arm or thigh. Onset of action 10–15 minutes.
AHS 2025 ED GuidelinesGreater Occipital Nerve Block
Local anesthetic (procedural)
Bupivacaine 0.5% 2–3 mL or lidocaine 2% 2–3 mL per side
No systemic vasoconstriction and no fetal drug exposure. The 2025 AHS ED update elevated greater occipital nerve block into the core bedside toolkit rather than a hidden rescue option.
More bedside detail
Cautions: Local infection at injection site Allergy to local anesthetics (rare) Local anesthetic systemic toxicity is rare but should be anticipated procedurally
Administration: Palpate the occipital protuberance, inject 1 cm lateral and inferior, and aspirate before injecting. Bilateral block is reasonable for bilateral headache. Avoid intravascular injection.
AHS 2025 ED GuidelinesMagnesium Sulfate IV
Electrolyte / NMDA antagonist
Magnesium sulfate 1–2 g IV over 15–30 min
Strongest evidence in migraine with aura. Consider as first-line adjunct for aura-predominant presentations.
More bedside detail
Cautions: Monitor for flushing, hypotension during infusion Check magnesium level if renal function borderline
Administration: Dilute 1–2 g in 100 mL NS. Infuse over 15–30 minutes. Burning at IV site is common — slow the rate.
AHS 2025 ED GuidelinesValproate Sodium IV
Anticonvulsant
Valproate sodium 400–1000 mg IV over 30 min
Particularly useful in patients with migraine + epilepsy comorbidity, or when dopamine antagonists and triptans are contraindicated.
More bedside detail
Cautions: Check pregnancy status before administration Monitor for hypotension during infusion
Administration: Infuse over 30 minutes. Dilute in 50–100 mL normal saline.
AHS 2025 ED GuidelinesDihydroergotamine (DHE) IV
Ergot alkaloid
DHE 1 mg IV (with antiemetic pretreatment)
Low headache recurrence rate compared to triptans. Best suited for prolonged migraine (>24h) or status migrainosus.
More bedside detail
Cautions: Must pretreat with antiemetic — DHE is highly emetogenic Avoid in hemiplegic migraine Avoid with CYP3A4 inhibitors
Administration: Give antiemetic (metoclopramide or ondansetron) 30 min before DHE. Administer DHE 1 mg IV push over 3 minutes.
AHS 2025 ED GuidelinesDroperidol IV/IM
Butyrophenone (dopamine antagonist)
Droperidol 2.5 mg IV or IM
Effective but underused due to FDA black box (QTc). In practice, QTc prolongation risk is low at migraine doses. ECG screening is standard.
More bedside detail
Cautions: Obtain ECG before administration — QTc monitoring required (FDA black box warning) Monitor for akathisia and dystonia
Administration: Obtain 12-lead ECG before dosing. Give IV push over 2 minutes or IM. Telemetry monitoring for 2–3 hours post-dose.
AHS 2025 ED GuidelinesChlorpromazine IV
Phenothiazine (dopamine antagonist)
Chlorpromazine 10–25 mg IV with IV fluid bolus
Effective but hypotension limits use. Pre-hydration with 500 mL NS bolus mitigates the main adverse effect.
More bedside detail
Cautions: Significant hypotension risk — co-administer 500 mL NS bolus Monitor for sedation and dystonia
Administration: Give 500 mL NS bolus before or concurrent with chlorpromazine. Infuse chlorpromazine slowly over 15–20 minutes.
AHS 2025 ED GuidelinesOlanzapine IM
Atypical antipsychotic
Olanzapine 5–10 mg IM
Emerging evidence supports efficacy comparable to first-line agents. Sedation may be a therapeutic benefit for patients in distress.
More bedside detail
Cautions: Sedation is common — warn patients Avoid combining with benzodiazepines (respiratory depression) Monitor blood pressure for orthostatic hypotension
Administration: IM injection into deltoid or gluteal muscle. Onset 15–30 minutes. Keep patient recumbent for 30 minutes.
AHS 2025 ED GuidelinesHaloperidol IV
Butyrophenone (dopamine antagonist)
Haloperidol 2.5–5 mg IV
Less sedating than chlorpromazine/olanzapine. Consider when sedation is undesirable but dopamine antagonism is needed.
More bedside detail
Cautions: Obtain ECG before administration Monitor for akathisia and dystonia
Administration: Obtain 12-lead ECG before dosing. Give IV push over 3–5 minutes.
AHS 2025 ED GuidelinesDexamethasone IV (Recurrence Prevention)
Corticosteroid
Dexamethasone 4–8 mg IV (single dose)
Does NOT treat the acute migraine — it prevents recurrence within 24–72 hours. Add to any first-line regimen, not as monotherapy.
More bedside detail
Cautions: Not effective for acute pain relief — adjunct only Use caution in diabetic patients (transient hyperglycemia)
Administration: Single IV dose at time of ED treatment. No taper needed for single dose.
AHS 2025 ED GuidelinesOpioids
Opioid analgesic
N/A — not recommended
AHS 2025 Class 3 prohibits opioids (including hydromorphone, morphine, meperidine) for primary migraine in the ED. Associated with longer ED stays, higher headache recurrence, and increased risk of medication overuse headache. If a patient has received opioids, document the clinical reasoning and consider transitioning to guideline-concordant therapy.
More bedside detail
Butalbital Combinations
Barbiturate combination
N/A — not recommended
High dependency potential. Contributes to medication overuse headache more rapidly than other acute treatments.