Migraine, in ER


Migraine headache is a common presenting complaint in the Emergency Department (ED).  While migraine is a common cause of headache it is important to consider other potential etiologies for the patients headache (see Headache Differential)

Headache Differential Diagnosis

  • Acute Glaucoma
  • Carbon Monoxide Poisoning
  • Acute or Chronic Subdural Hematoma
  • Subarachnoid Hemorrhage
  • Benign intracranial hypertension (pseudotumor cerebri)
  • Cluster Headache
  • Carotid dissection
  • Myofascial cervical Neck Pain
  • Sinus Headache
  • Intercranial Neoplasm
  • Meningitis/Encephalitis
  • Postconcussion Syndrome
  • Temporal Arteritis
  • Temporomandibular joint dysfunction
  • Mastoiditis
  • Medication induced headache

**This is an incomplete differential diagnosis, but could be a starting point for your consideration**

Some elements of the history which can be helpful is the chronicity of the headache and whether they have had previous similar headaches. Also eliciting the quality and location (OPQRSTAAA) of the headache can be important. I typically look for patients to endorse symptoms consistent with the POUND mnemonic.

  • Pulsatile quality of headache
  • One-day duration (four to 72 hours)
  • Unilateral location
  • Nausea or vomiting
  • Disabling intensity

Since I want to know about the disabling intensity I commonly use the FIFE mnemonic when seeing patients to determine the impact of their headache on daily activities such as work or school. I then try to explore the patients specific ideas and fears as well as their expectations. Often patients have an expectation to have a CT or MRI and I try to address there fears and elicit why they feel that imaging is warranted.

Next it is important to conduct at thorough Head and Neck exam (HEENT) as well as Cranial Nerve exam. Spending time here is critically important to pick up deficits or findings which should point to alternative diagnoses.

If after your history and physical exam you are convinced this is a Migraine with our without aura you can then turn your attention to treatment. Typically in the ED we use multimodal therapy to target different pain receptors. I always try to elicit a pain severity on a scale of 0-10 from the patient prior to commencing therapy to be able to gauge effectiveness of my intervention(s).

One regimen suggested by Gupta et al. in CFP Jan 2014 for severe migraine is:

  • 1-L bolus of IV normal saline solution
  • 10 mg of IV prochlorperazine
  • 25 mg of IV diphenhydramine
  • 30 mg of IV ketorolac
  • 10 mg of IV dexamethasone

*The authors of this paper suggest that this be provided all at once , rather than stepped care.

In my personal practice I find that typically I provide patients with:

  • acetaminophen 975 mg PO (if not previously taken within 4 hours)
  • ketorolac 30 mg IV/IM *(If no contraindication, I reduce my dose in elderly or those with renal issues)
  • metoclopramide 10 mg IV
  • normal saline 1-L IV over 1 hour
  • dexamethasone 10 mg IV

Curious what is recommend for therapy for pregnant patients be sure toe check out the reference fro ACP Internits below.

Have a question or comment? Leave us a message below. Be sure to also suggest topics for us to cover in future.


  1. Gupta S, Oosthuizen R, Pulfrey S. Treatment of acute migraine in the emergency department. Canadian Family Physician. Jan 2014. 60(1) pp. 47-9.
  2. http://www.fpnotebook.com/neuro/headache/MgrnHdch.htm
  3. http://www.aafp.org/afp/2011/0201/p271.html
  4. www.acpinternist.org/archives/2005/06/special.pdf

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