Migraines are severe headaches causing intense throbbing pain, sensitivity to light and sound, and nausea. While many manage attacks at home, some become debilitating or present with concerning symptoms requiring emergency medical attention. The emergency room (ER) provides specialized care for acute symptoms and to rule out other serious conditions.
When to Go to the ER for a Migraine
Certain symptoms with a migraine attack indicate a need for immediate emergency care, as they might signal a more serious underlying health issue. A “thunderclap headache,” characterized by sudden, severe head pain reaching maximum intensity within 60 seconds, warrants an immediate ER visit. This can indicate life-threatening conditions like a ruptured aneurysm or bleeding in the brain.
An ER visit is also advisable if a migraine includes new or worsening neurological symptoms, such as numbness, weakness on one side of the body, vision changes, speech difficulties, confusion, or loss of consciousness. Headaches following head trauma, or those with a high fever and stiff neck, also require urgent medical evaluation. A migraine lasting over 72 hours without relief from usual medications, known as status migrainosus, may also necessitate ER intervention.
Medications Used in the ER for Migraines
Emergency rooms administer a combination of medications, often intravenously (IV), to rapidly alleviate acute migraine symptoms. Antiemetics are frequently given to address the common and distressing symptoms of nausea and vomiting associated with migraines. Prochlorperazine (Compazine), metoclopramide (Reglan), and ondansetron (Zofran) are common examples.
Nonsteroidal anti-inflammatory drugs (NSAIDs) are a common component of migraine treatment in the ER due to their pain-relieving and anti-inflammatory properties. Ketorolac (Toradol) is a commonly administered NSAID, often given intravenously or intramuscularly for rapid effect. Diclofenac is another effective NSAID.
Triptans, which are migraine-specific medications, may be used for patients who do not respond to initial treatments or for those with severe migraines without cardiovascular contraindications. While oral triptans are common for home use, subcutaneous sumatriptan (Imitrex) or intranasal formulations are more typical in the ER setting for faster absorption.
Corticosteroids, such as dexamethasone, are sometimes administered to help prevent headache recurrence within 24 to 72 hours after the acute attack. Although their role in immediate pain relief is less established, they can be given intravenously or orally.
Atypical antipsychotics like haloperidol (Haldol) are also employed as rescue therapy for refractory migraines.
Magnesium sulfate is another option that can be given intravenously, especially for patients with a history of migraine with aura or those who are pregnant.
Intravenous fluids, typically normal saline solution, are often initiated to rehydrate patients, especially those who have experienced persistent nausea and vomiting, which can exacerbate migraine symptoms.
What to Expect During an ER Migraine Visit
Upon arrival at the emergency room for a migraine, the process typically begins with triage, where medical staff assess symptom severity and gather a brief medical history. This initial assessment helps determine care urgency and if any “red flag” symptoms are present. Following triage, a physical examination will be performed, often including a neurological assessment.
Diagnostic tests, such as a CT scan or MRI, may be ordered to rule out other serious conditions that mimic migraine symptoms, such as stroke, brain hemorrhage, or tumors. A lumbar puncture may also be performed if meningitis or subarachnoid hemorrhage is suspected, especially if imaging results are normal but concerning symptoms persist. These tests primarily exclude other diagnoses, as migraines are typically diagnosed clinically.
Once a migraine diagnosis is confirmed or serious conditions are ruled out, an intravenous line is typically inserted for rapid administration of medications and fluids. Medications are then given based on the patient’s symptoms and medical history. During treatment, comfort measures like a quiet, darkened room are often provided. The patient’s response to treatment and vital signs are continuously monitored.
Post-ER Care and Follow-Up
After the acute migraine attack is managed, discharge instructions are provided. These typically include guidance on managing potential medication side effects, avoiding driving, and when to seek further medical attention if symptoms worsen or return. Patients are advised to continue resting and hydrating.
A follow-up appointment with a primary care physician or neurologist is an important next step. ER treatment provides acute relief but is not a long-term solution for migraine management. A healthcare provider can help develop a comprehensive plan, including preventive medications, lifestyle adjustments, and strategies for managing future attacks at home. This ongoing care aims to reduce migraine frequency and severity and improve overall quality of life.