Treatment of Acute Migraine in the Emergency Department

Introduction

Migraine is a common reason for visits to the emergency department (ED). Intense, one-sided headaches, light sensitivity, and nausea characterize it. Doctors diagnose it based on symptoms like pulsating pain, one-day duration, one-sided pain, and nausea or vomiting (known as POUND). Although the exact cause is not fully understood, it is believed to involve brain dysfunction and blood vessel narrowing. There are many treatments used in the ED, but not all are equally effective, and some might even lead to return visits to the ED. This article aims to provide a reliable and evidence-based approach to treating acute migraine in the ED.

When Should Someone Seek Emergency Care for a Migraine?

Headaches often prompt individuals to seek emergency care, although not every instance requires immediate medical attention. Many individuals arriving at the emergency room due to migraine pain are experiencing a typical migraine attack rather than a medical emergency. Nevertheless, there are specific circumstances where seeking emergency care becomes crucial:

1. Unusual or Severe Symptoms: If the migraine symptoms deviate from the norm or intensify significantly, it may indicate a need for immediate medical attention. These changes could be indicative of serious conditions such as:

• A stroke.

• Meningitis, a brain infection.

• Aneurysm (a protruding blood vessel in the brain that poses a risk of rupture, leading to a stroke-like condition).

2. Rapid Onset of Symptoms: Normally, migraine symptoms gradually worsen over hours, changing how one feels in the days leading up to the headache. However, if one experiences sudden and intense head pain, it is crucial to go to the emergency room. This sudden and severe headache, known as a "thunderclap" headache, can signal a potential stroke rather than a typical migraine episode.

3. Persistent Severe Migraines: If one suffers from severe migraines lasting more than 72 hours (three days) that do not improve with typical migraine medications like triptans, it is important to seek medical care at an emergency room or urgent care clinic. These prolonged and intense migraines, also known as status migrainosus, require prompt attention.

If someone experiences a new or severe headache accompanied by any of the following symptoms, it is crucial to seek immediate medical attention at the emergency room:

• High fever, stiff neck, numbness, muscle weakness, confusion, double vision, or vision loss.

• Difficulty walking or speaking clearly.

• Loss of consciousness, uncontrolled nausea, or vomiting.

• Extreme sensitivity to light and a sudden rash.

• Head pain following an injury or fall.

• Headache worsens with coughing or sudden movements.

• Age 50 or older.

• Inability to stand, even with support from a chair or railing.

• Unequal pupil size.

• Drooping eyelid.

• If a person experiences loss of speech during migraine attacks, consider wearing a medical ID bracelet or carrying a card with information about one’s diagnosis at all times. If someone the patient knows suffers from this type of migraine, accompany them to the hospital or provide relevant information to emergency personnel.

How Migraine Is Diagnosed in ED?

If heading to the emergency room with a serious headache, consider bringing a pillow, dark glasses, and earplugs for enhanced comfort due to the bright and noisy hospital environment.

Upon arrival, medical professionals will conduct various tests to identify underlying health conditions causing the symptoms. They may administer treatments to alleviate pain and discomfort. The ER staff will thoroughly assess symptoms, considering the possibility that migraine could be the cause. Provide detailed information:

• Share all symptoms without minimizing or omitting any.

• Report any new or different symptoms experienced.

• Disclose all medications and supplements taken in recent days.

• Inform them about any previously effective migraine treatments.

If experiencing vision problems, an eye exam may be conducted. Blood or urine tests might be performed to rule out conditions like diabetes, infections, or thyroid problems leading to headaches or other symptoms. In certain cases, specific tests may be performed to investigate potential causes of severe head pain:

• CT Scan: Detailed X-rays of the brain to examine abnormalities.

• MRI Scan: Magnetic fields and radio waves generate detailed brain and blood vessel images.

• Spinal Tap: Testing a small sample of spinal cord fluid to check for bleeding, tumors, or infections causing the headache.

What Is the Treatment of Acute Migraine in the Emergency Department?

• Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): Several nonsteroidal anti-inflammatory drugs (NSAIDs), including Ketorolac, have demonstrated efficacy in randomized trials for acute migraines. Ketorolac, available in intramuscular and intravenous forms, is a viable option in the ED. NSAIDs, when used as monotherapy, offer consistent relief and are a reasonable choice due to their proven effectiveness.

• Acetaminophen: Acetaminophen is a commonly used medication for migraine relief. Its low cost, wide availability, and minimal side effects make it a preferred first-choice drug. While studies have not conclusively shown additional benefits when combined with standard migraine therapies, Acetaminophen remains a reasonable option, especially for patients with minor migraines who have not taken it in the past four hours.

• Triptans: Triptans, serotonin 1B/1D agonists, are widely accepted for outpatient migraine management. They provide effective relief in oral, nasal, and subcutaneous forms. However, their use in the ED is limited due to contraindications, side effects, and varying efficacy in severe migraine cases.

• Ergotamine: Dihydroergotamine (DHE) is another option for abortive therapy, acting similarly to triptans. Studies comparing DHE monotherapy with antiemetic therapy have shown mixed results, making it a less preferred choice in the ED setting due to potential side effects and lack of superiority over other treatments.

• Intravenous Fluids and Antiemetic Medications: Dehydration exacerbates migraines; therefore, IV fluids can alleviate symptoms, although strong evidence is limited. Antiemetic medications like Metoclopramide, Chlorpromazine, and Prochlorperazine are effective in reducing pain and nausea. Diphenhydramine can mitigate the risk of akathisia, making these medications valuable for acute migraine in the ED.

• Butyrophenones (Haloperidol and Droperidol) and Opioids: Haloperidol and Droperidol have shown efficacy in migraine treatment but are reserved for refractory cases due to side effects. Opioids, while occasionally used, are less effective than other options and may lead to recurrence and functional disability, making them a less desirable choice.

• Dexamethasone: Dexamethasone, when used as an adjunct to standard therapy, reduces the likelihood of migraine recurrence within 72 hours. While it does not significantly impact acute pain scores, it offers a valuable preventive aspect, making it a viable addition to the treatment regimen.

Conclusion

In conclusion, managing acute migraines in the emergency department requires careful consideration of symptoms and appropriate treatment options. It is essential for individuals experiencing unusual or severe symptoms, rapid onset of symptoms, or persistent severe migraines lasting more than 72 hours to seek immediate medical attention. Medical professionals in the emergency room conduct thorough assessments, including various tests, to identify underlying causes. Treatment options include nonsteroidal anti-inflammatory drugs (NSAIDs), Acetaminophen, triptans, Ergotamine, intravenous fluids, antiemetic medications, and adjunct therapies like Dexamethasone.