Immediate ED approach

1. ABC, monitoring, IV access
   • Recheck BP manually after analgesia/antiemetic and document both readings.
   • Check temperature, GCS/mental status, pain score, glucose.
   • Keep NPO initially if vomiting or possible need for imaging/LP.
   • Dark, quiet room and IV fluids if clinically dehydrated from emesis. Routine large-volume fluids alone are not migraine treatment.
2. Focused history, before treating if possible
   • Exact time and speed of onset: Did it peak within seconds to 1 minute? Was it “first/worst” or maximal at onset?
   • Is this the same as prior migraine: location, severity, evolution, associated symptoms, duration, and response to prior rescue therapy?
   • Precipitant: exertion, sex, Valsalva, trauma, neck manipulation, cocaine/amphetamines/cannabis, anticoagulants/antiplatelets, infection, immunosuppression.
   • Medication details: what preventive medication was missed, usual acute drugs, number of analgesic/triptan days per month, and any recent medication changes.
   • Ask specifically about neck pain, fever, rash, visual loss/red painful eye, diplopia, weakness/numbness, dysarthria, seizure, syncope, confusion, positional component, and severe hypertension history.
3. Examination
   • Full neurological examination, including gait if safe.
   • Funduscopy for papilledema, pupils/EOMs, visual fields.
   • Neck stiffness and neck tenderness/Horner syndrome.
   • Eye examination including visual acuity, red eye/corneal haze, and IOP if acute angle closure is plausible.
   • Skin/rash and sinus/ear/dental exam only if suggested clinically.
   • Repeat neurologic exam after initial treatment.

When to image or investigate now

• Thunderclap or abrupt maximal-at-onset headache
• First or worst headache, important change in established migraine pattern, or progressive severity
• Focal deficit, seizure, confusion, reduced consciousness, papilledema
• Fever/meningism
• Persistent or unexplained vomiting
• Anticoagulant use, trauma, immunosuppression, malignancy
• Exertional/sexual/Valsalva onset, neck pain, Horner syndrome
• Persistent severe BP elevation with neurologic symptoms or end-organ injury

• A good-quality non-contrast CT performed within 6 hours of onset in a neurologically intact patient can be sufficient to exclude SAH in the appropriate setting.
• If presentation is beyond 6 hours, CT is nondiagnostic, or clinical suspicion remains significant, proceed with LP or CTA using your local pathway and shared decision-making. ACEP recommends LP or CTA for patients still at risk after a negative CT. The ACEP headache policy summary supports this approach.
• Consider CTA head/neck for dissection/RCVS, and CTV/MRV if CVT is plausible. MRI is preferable for many nonhemorrhagic structural, inflammatory, or posterior-fossa processes. Bradley and Daroff's Neurology in Clinical Practice, CT/MRI discussion, pp. 2673-77 in the library extract.

If examination is normal and this is a typical migraine attack

A practical first-line regimen

• Prochlorperazine 10 mg IV, slow administration
  Consider diphenhydramine 25 mg IV if your departmental protocol uses it or if akathisia/EPS risk occurs.
• Ketorolac 15 mg IV or 30 mg IV/IM, if no renal impairment, active GI bleeding/ulcer, NSAID allergy, significant dehydration, or high bleeding risk.
• IV crystalloid only as needed for volume depletion from vomiting.

• Metoclopramide 10 mg IV over 10-15 minutes, with treatment/observation for akathisia or dystonia.

If incomplete response

• Reassess at 30-60 minutes and repeat neurologic examination.
• Consider dexamethasone 10 mg IV once, particularly if recurrence risk is high. It is primarily for reducing relapse after discharge, not rapid analgesia.
• SC sumatriptan 6 mg can be useful if this is clearly migraine and there is no vascular contraindication. Avoid it if BP remains uncontrolled, or if you have concern for stroke/TIA, CAD/vasospasm, dissection, or an unexcluded secondary vascular headache.
• DHE is another specialist/protocol-dependent option, but do not combine with a triptan within 24 hours and avoid in vascular disease/uncontrolled hypertension.

What not to do

• Do not give opioids, especially hydromorphone, for presumed migraine. They have poorer migraine outcomes, contribute to medication-overuse headache, and can increase return visits. The updated AHS recommendation is Level A “must not offer” for IV hydromorphone.
• Do not acutely lower BP solely because it was initially high during severe pain/vomiting if it normalizes and there is no end-organ injury. Pain and nausea commonly elevate BP. Treat a hypertensive emergency only if BP remains markedly elevated with objective acute target-organ injury.
• Do not use a normal neurologic examination alone to rule out SAH if onset was thunderclap or history is concerning.
• Do not use an oral drug as the main initial therapy while he is actively vomiting.
• Do not simply restart or alter his preventive regimen in the ED without confirming the actual drug, dose, adherence issue, contraindications, and outpatient plan.

Suggested ED documentation/disposition

• Document why this attack is consistent with his established migraine phenotype.
• Discharge with a clear rescue plan, antiemetic if needed, and prompt follow-up for preventive-medication adherence.
• Give return precautions for thunderclap recurrence, new focal symptoms, fever/neck stiffness, persistent vomiting, altered consciousness, visual loss, or a new atypical headache.

Latest acute migraine guideline for adults in the ED

Practical ED implication

• Prochlorperazine 10 mg IV, usually with monitoring for sedation, dystonia, or akathisia
• Consider diphenhydramine 25 mg IV according to local protocol or to treat EPS/akathisia
• Add ketorolac IV/IM if no renal dysfunction, significant dehydration, GI bleed/ulcer risk, anticoagulation-related bleeding concern, or NSAID allergy
• Alternatively, metoclopramide 10 mg IV if prochlorperazine is unavailable or unsuitable
• Consider dexamethasone IV mainly to reduce post-discharge recurrence, not as the main immediate analgesic
• Use SC sumatriptan only if diagnosis is secure and there is no uncontrolled hypertension, coronary/cerebrovascular disease, vasospastic disease, or concern for dissection/RCVS/secondary vascular headache.

For outpatient acute therapy

1. Mild to moderate attacks: NSAID or acetaminophen early in the attack, with an antiemetic when nausea is prominent.
2. Moderate to severe attacks or NSAID failure: a triptan is generally the main migraine-specific option if no vascular contraindication.
3. If triptan is contraindicated, ineffective, or poorly tolerated: consider a nonvasoconstrictive agent:
   • Gepants: ubrogepant, rimegepant, zavegepant nasal spray
   • Ditan: lasmiditan, noting major driving/impairment restrictions
4. Use a non-oral route when vomiting or marked gastric stasis makes oral absorption unreliable.
5. Avoid frequent acute-medication use. A practical threshold for reassessment is use on more than 2 to 3 days per week or escalating monthly acute-medication days, because of medication-overuse headache risk.