Migraines are complex neurological events, and determining when to seek emergency medical care is a decision for anyone experiencing a severe attack. While most migraines can be managed with at-home medications and rest, certain symptoms suggest a medical crisis that requires immediate attention. Understanding the distinction between a typical migraine and a potentially life-threatening event guides the right choice. This guidance focuses on the criteria for deciding between home care, consulting a specialist, or making an immediate trip to the Emergency Room (ER).
Specific Symptoms That Require Immediate Emergency Attention
The most important factor in deciding to go to the ER is the presence of “red flag” symptoms that are atypical for a standard migraine, as these may signal a serious underlying condition such as a hemorrhage, stroke, or meningitis. The most alarming is the “thunderclap headache,” defined as an extremely severe headache that reaches its maximum intensity in less than 60 seconds. This sudden, explosive onset of pain, often described as the “worst headache of your life,” is a medical emergency that must be investigated immediately to rule out conditions like a subarachnoid hemorrhage.
Other neurological changes that accompany a headache mandate immediate ER evaluation. These symptoms include new-onset confusion, difficulty speaking, slurred speech, or a significant change in mental status. Any new weakness, numbness, or paralysis on one side of the body, or new difficulty with balance or walking, can indicate a stroke or other cerebral event. New visual changes, such as double vision or a complete loss of vision, are also serious indicators.
A headache accompanied by a high fever and a stiff neck warrants immediate emergency attention, as this combination can point to a serious infection like meningitis. A severe headache that follows a recent head injury, or one that is made significantly worse by coughing, sneezing, or straining, should also be evaluated in an emergency setting. If any of these red flags are present, you should call emergency services or go to the nearest ER immediately.
When to Consult Your Regular Doctor or Urgent Care
There are instances where a migraine is severe but does not present with life-threatening red flags requiring an ER visit. The primary scenario for seeking non-emergency acute care is a prolonged attack known as status migrainosus. This is defined as a migraine attack that lasts for more than 72 hours and does not respond to a person’s usual acute medications, such as triptans. This stage requires medical intervention to break the pain cycle.
A common reason to seek urgent medical attention is when a migraine is accompanied by intractable vomiting, meaning you cannot keep down any oral medication or fluids. This persistent vomiting poses a significant risk of dehydration and electrolyte imbalance, which can worsen the headache and make oral medications ineffective. Receiving intravenous (IV) fluids and anti-nausea medication can stabilize your condition and allow subsequent pain medication to work.
Contacting your primary care provider or neurologist is the preferred first step, as they may be able to administer rescue medications in an outpatient setting. If your regular doctor is unavailable, an urgent care facility is a more appropriate setting than the ER. Urgent care is better suited for managing severe but stable conditions. This approach ensures you receive the necessary parenteral treatments without utilizing the high-acuity, high-cost resources of the emergency department.
What to Expect During Emergency Migraine Treatment
Upon arrival at the ER for a severe headache, the medical team’s first priority is to quickly rule out dangerous secondary causes associated with red flag symptoms. This triage process involves a neurological assessment and may include diagnostic imaging, such as a computed tomography (CT) scan, especially if a thunderclap headache or new neurological deficits were reported. A lumbar puncture, or spinal tap, may also be performed if an infection or bleeding around the brain is suspected despite a negative CT scan.
Once life-threatening conditions have been excluded, the focus shifts to acute pain management, often using a “migraine cocktail” of IV medications. Treatment begins with intravenous fluids, such as a saline solution, to address potential dehydration. Anti-nausea medications, like metoclopramide or prochlorperazine, are administered, as they treat vomiting and possess properties that can help relieve the headache itself.
The core pain relief often involves a non-steroidal anti-inflammatory drug (NSAID), with ketorolac being a common choice for its intravenous formulation. Other medications that may be administered include dopamine antagonists or, in cases of status migrainosus, dihydroergotamine (DHE) or a short course of corticosteroids like dexamethasone. The goal of this emergency treatment is to achieve significant pain relief and allow the patient to return home, but it does not replace the need for long-term management with a headache specialist.