Migraine in the Emergency Department
Thank you to Serena Orr, MD; Vanessa Doyle, MD; Samantha Irwin, MD; Shahbaz Syed, MD; and Juliana VanderPluym, MD for their contributions to this spotlight!
At Home Treatment Strategies to Try Prior to Visiting the Emergency Department
By: Vanessa Doyle, MD
No one likes to spend hours of their day sitting in an emergency department (ED) with a throbbing headache. Yet, when a headache is severe and nothing that you’ve tried at home works, sometimes the ED is the last resort available.
Headaches are one of the most common reasons for visiting the ED. In a United
States-based study, headache was the first listed diagnosis in 2.4% of ED visits, and 34.6% of headache visits were accounted for by migraine. That’s a significant number of visits for migraine patients. Ultimately, reducing the number of ED visits for migraine is the goal. There is evidence to suggest that the use of migraine prophylaxis (medications taken on a daily basis to prevent migraines) and migraine specific acute therapies (medications taken once the headache pain begins) reduces ED visits. Therefore, one of the goals of migraine treatment is to optimize the use of these prophylactic and acute therapies so as to prevent ED visits (see diagram).
Sometimes these medications are not effective, and you need to try other strategies in an attempt to avoid an ED visit. Before coming to the ED, many migraine patients have already tried at least one rescue medication without adequate relief. Migraine tends to become more difficult to treat as it becomes more prolonged, because attacks generally become more severe with time. Many clinical trials suggest that when a person presents to the ED, on average, the headache has been going on for about 24 to 72 hours. There are some strategies that you can try at home prior to presenting to the ED. These include:
- Stay well hydrated. Research has shown that dehydration can trigger migraines and that staying well hydrated may improve quality of life in individuals with migraine. This becomes particularly difficult if you experience nausea and vomiting with your headache.
- Try to rest in a quiet, dark room away from loud noises and bright lights. You can also apply a cold, moist cloth or ice pack to your forehead and temples.
- Try acute pain medications. These medications include the class of drugs called NSAIDs (non-steroidal anti-inflammatories), including ibuprofen, naprosyn, ketorolac or aspirin. These medications treat all types of pain, not just migraine pain, but they can help stop the headache pain if taken early. Some of these medications require a prescription, whereas others are over the counter.
- Try migraine-specific rescue treatments. These are medications that are taken at the initial onset of pain and geared towards treating migraine pain. Triptans (eg. sumatriptan) and ergotamines are examples of migraine-specific rescue medications. There are many different types of drugs in this class, and many different types of administration routes, including pills, wafers that melt on your tongue, injections that you administer yourself, nasal sprays, etc. These medications tend to work rapidly to stop the headache pain, but they are most effective when taken early, when the pain is still mild. Is it best to take these medications at the first sight of pain. These medications are not safe to use if you have cardiovascular disease, angina, prior stroke(s), poorly controlled high blood pressure or if you are pregnant. These medications can be taken together with NSAIDs, like naprosyn.
- Try medications to help with nausea and vomiting. Since nausea and vomiting are common migraine symptoms, medications to treat them are often used, alone, or in combination with other medications to alleviate the migraine. These include: metoclopramide, ondansetron, prochlorperazine and dimenhydrinate.
- Blau JN. Water deprivation: a new migraine precipitant. Headache 2005;45(6):757-9
- Gelfand A & Goadsby PJ. A Neurologist’s guide to acute migraine therapy in the emergency room. Neurohospitalist 2012, 2(2): 51-59.
- Orr SL et al. (2014). Canadian Headache Society systematic review and recommendations on the treatment of migraine pain in emergency settings. Cephalalgia, 0(0): 1-14.
- Spigt M, Weerkamp N, Troost J, van Schayck CP, Knottnerus JA. A randomized trial on the effects of regular water intake in patients with recurrent headaches. Fam Pract 2012;29(4):370-5
When to Worry about a Migraine and Seek Emergency Medical Attention
By: Samantha Irwin, MD
If you have a diagnosis of migraine and the headache that you are experiencing is similar to your previous headaches, there is likely no need to seek medical attention, unless you are unable to cope with the pain or to relieve it with strategies used at home. However, if your migraine persists for more than 72hrs, it is appropriate to contact your Headache physician or, if unavailable, to seek treatment in the Emergency Department (ED) for a condition known as “Status migrainosus.” Status migrainosus is defined as a migraine lasting greater than 72hrs without a pain free interval. Status migrainosus tends to be treated differently than shorter migraines, and often requires intravenous treatments that are administered in an infusion center or hospital setting.
It is important to recognize that, even if you have a diagnosis of migraine, it is possible for you to experience other headaches. If your headache is different from your migraines, then it is usually best to bring the new headache to medical attention. In cases where you experience a different headache that is also severe or has alarming features, an ED visit may be warranted.
It can be difficult to decipher whether or not you should seek ED care for a headache. Some headache features are considered “red flags”, in that the symptoms and signs associated can indicate a serious underlying cause for the headache. On the other hand, experiencing a red flag symptom does not necessarily mean that the headache is life-threatening or that you are in need of ED attention. In some circumstances, the presence of one of these red flags may warrant an immediate ED visit, while in others, it may be best to address your concerns with your primary care provider or your Headache physician. It is not possible to provide specific advice about where to seek care for each possible scenario. If you are unsure, you can always call a health information line for advice.
Physicians often use the acronym ‘SNOOPY” to keep track of headache red flags (see diagram above for acronym and below for detailed explanation). If your headache is different from your typical migraines and has one of the red flag features described in the acronym, it is reasonable to seek medical attention. Some of the features to be concerned about when experiencing a headache include the following:
S: Systemic symptoms & signs: Headaches accompanied by systemic signs and symptoms can be concerning. Some of these signs and symptoms include, but are not limited to, the following: Fever, neck stiffness, vomiting, new rashes, headaches with an underlying bleeding disorder, underlying cancer diagnosis or underlying immune-compromised state (HIV/AIDS), or headache after recent head trauma.
N: Neurologic symptoms & signs: If you have neurological signs or symptoms with your headache, you should seek medical attention. Examples of concerning neurologic signs or symptoms include: Seizures, trouble with vision, lack of coordination or new clumsiness, impairment in strength on one side, impairment in level of consciousness or persistent vomiting.
- Onset sudden: If the onset of your headache is sudden, whereby it reaches maximum intensity over less than 1 minute, or if you have recently developed headaches, without ever having a prior headache, you should seek medical attention.
- Older: Anyone who develops his or her first headache over the age of 50 years should seek medical attention. If however, you are experiencing your typical migraine, but happen to be over the age of 50 years, medical attention is not necessary.
- Occipital headache in children: If your child complains of a headache that is situated at the back of the head, they should be evaluated by a physician.
- Previous headache history (new/first/worst/different/change): If the headache you are experiencing is changed from your prior headache type, if this is the worst headache you have experienced, or if this is your first severe headache, you should seek medical attention. In addition, if your headache is not responding to over the counter treatments or your prescribed migraine medication and you are unable to cope with the pain, or if a new headache is waking you from sleep, you should seek medical attention.
- Progressive (accelerated) of headache: If your headache is occurring more frequently, if it is very severe or becoming more severe each day, and/or if it is persisting despite trying pain relief options at home, you should seek medical attention.
- Precipitated by valsalva: If your headache is made worse by bearing down, coughing, sneezing, exertion, or sexual intercourse, you should seek medical attention.
- Postural headaches (upright or supine): If your headache is consistently worse in the morning or when lying flat, you should seek medical attention.
- Pregnancy or post partum state: If you develop a headache during pregnancy or during the first 6 weeks post partum, you should seek medical attention.
Y: Younger age: Any child describing or indicating a headache who is younger than age 2-3 years should be evaluated by a physician.
This list of red flag signs and symptoms is provided for informational purposes. If you are unsure about how to address your headache, it is best to consult with a health information line, given that individual circumstances vary considerably.
- Family Practice Notebook: http://www.fpnotebook.com/neuro/exam/HdchRdFlg.htm
- Dodick D. “Headache as a symptom of ominous disease. What are the warning signals?” Postgrad Med. 1997. May; 101(5):46-50, 55-6, 62-4.
- Dodick DW. “Clinical clues and clinical rules: primary vs. secondary headache.”Adv Stud Med. 2003;3(6C):S550-S555.
- Hainer B.L., Matheson E.M. “Approach to Acute Headache in Adults.” Am Fam Physician. 2013 May 15;87(10):682-687.
What to Expect of the Assessment in the Emergency Department
By: Shahbaz Syed, MD
When thinking about headaches, emergency care providers tend to group them into two categories; benign (not harmful) and malignant (potentially harmful). During the care provider’s assessment and management, they are looking for/seeking to identify features that are suggestive of a concerning cause for the headache. If no concerning features are present and a diagnosis of migraine is made, then the care provider will move on to deciding on how to manage the headache pain.
There are many different diseases that can cause worrisome headaches in patients. However, the majority of headaches seen in the Emergency Department (ED) are benign.
During the history taking; the part of the assessment where the care provider asks you questions, they will seek to determine if any concerning characteristics are present, and, if not, whether your headache meets criteria for one of the benign headaches, most commonly migraine in this setting. The care provider will ask questions seeking to identify any potential ‘red flags’ (features that may be suggestive of a more serious cause for the headache; see diagram in “When to worry about a migraine and seek medical attention”). In identifying red flags, the characteristics of the headache are important to the physician, for example; how long did it take to reach its very worst point? Other examples of worrisome headache characteristics include: fever, neck stiffness, significant vomiting, visual changes, weakness or numbness, a headache that wakes a person at night, a headache in the elderly or a headache in an individual who is immunocompromised.
After taking a history and asking questions as above, the physician will then conduct a physical exam, the purpose of which is to look for any abnormalities within the nervous system of the patient. In particular, they will look for any weakness, sensory loss, or problems with coordination/balance. The identification of any neurologic abnormality is of concern during a headache assessment, and will most likely prompt further testing and/or consultation.
The vast majority of patients will not require any investigations when presenting to the ED with headache. However, in certain cases when the healthcare provider has concerns for a serious underlying cause for the headache, they may recommend performing further investigations such as a CT scan of the head or a lumbar puncture (where a sample of fluid is collected from around the spinal cord).
Questions to Ask the Emergency Physician
By: Shahbaz Syed, MD
Most patients presenting to the Emergency Department (ED) with a headache will not need any imaging (eg. a CT scan or an MRI). If there are no concerning features on history or physical exam, it is usually unnecessary to carry out further investigations. If you are receiving a CT or an MRI scan, it is reasonable to ask the physician why they believe this is necessary, to ensure that imaging is only undertaken when appropriate.
When a patient has frequent visits to the ED due to migraine pain, and specific treatments have been effective for them in the past, the healthcare provider should be made aware of these treatments. If you have previously had specific treatments for your migraines that have alleviated the pain, then you should ask your ED care provider if it is reasonable to use the same treatments during this particular visit.
If you are ultimately diagnosed with a migraine during your visit, it is also reasonable to ask the healthcare provider if there are any infusion centers available in the community for the next time that you experience a severe migraine that does not resolve with treatment at home (to avoid another visit to the ED). Along the same lines, if you do not have a community provider to look after your migraines, you can ask the healthcare provider for a referral to a specialist, or for resources in the community to help you optimally manage your migraines in the long term.
If you are a patient who frequently develops migraines, or who often has headaches, it may be worth asking the physician if steroids would be beneficial for you. In some patients, steroids have been shown to be beneficial at preventing a rebound or ‘bounce-back’ headache within the days following discharge from the ED.
Marx, J. Hockberger, R. Walls, R. (2014). Rosen’s Emergency Medicine, 8th Edition. Philadelphia, PA. Saunders, Elsevier.
What to Expect of Migraine Treatment in the Emergency Department
By: Serena L. Orr, MD
There is a vast array of treatment options to relieve migraine in the Emergency Department (ED). The majority of the interventions given to relieve migraine in the ED are pharmacologic, although a couple of non-pharmacologic interventions are also available. The main non-pharmacologic interventions used in the ED are intravenous fluids and patient education. Though ED care providers most often do give intravenous fluids and provide patient education, there is a need for high quality research studies to assess whether these interventions are helpful or not. In the interim, because these interventions are unlikely to be harmful, they are reasonable options to use as part of a migraine treatment plan in this setting.
Pharmacologic interventions used to treat acute migraine come in a variety of forms: some are given by mouth, while other options are inhaled, given by intravenous or by injection. The majority of the medications that have been studied for use in the ED setting are given by intravenous, but a few other options are available. There are over 20 different medications that have been studied for relieving migraine in the ED1. Very few of these medications are migraine-specific, as most have other indications for which they are used. For example, many of these medications are also anti-nauseants, some are used to relieve all types of pain, while others are used in higher doses as antipsychotics (see Table 1). There are varying levels of evidence associated with medications used for migraine in this setting. For example, there is relatively strong evidence that prochlorperazine, sumatriptan, metoclopramide and ketorolac are effective for migraine relief in the ED1, whereas opioid medications, like morphine and tramadol, have less evidence for efficacy1 and may be associated with higher rates of return visits within a week of discharge from the ED2. It is not uncommon for emergency physicians to use a combination of two or more medications to try and break the migraine. There is some evidence that combination therapy is more effective than using a single medication3.
Because of the wide variety of treatment options available for relieving migraine in the emergency department, your emergency care provider will need some information from you so that they can chose the best treatment. First of all, it will be important for you to tell the ED care provider whether or not you tried any treatment at home prior to visiting the ED. This is important because it can affect which treatments will be most effective and safe in the ED. For example, if you already took a triptan at home, your physician will probably avoid giving you another triptan or an ergot alkaloid medication like dihydroergotamine. The duration of your migraine will also impact the treatment decision. Triptans appear to be most effective in the first few hours of a migraine4. Therefore, your care provider will most likely avoid giving you a triptan if your migraine has been protracted. Another important factor in selecting the best medication pertains to safety: you should tell the ED care provider if you are taking any other medications, because some of the medication options can have interactions with other medications. For example, if you are taking an antipsychotic medication in the dopamine antagonist class, then your ED care provider will likely try to avoid using medications in that class, so as to reduce the risk of unwanted side effects. Also, if you have any underlying medical conditions, this will be taken into consideration in selecting which treatment option to use for your migraine. It is very important for you to share all of this information with the emergency care provider, so as to allow for the selection of a safe intervention that is likely to be effective.
If you have any particular preferences for treatment, be sure to express those to your emergency care provider. For example, you may have received treatments that have been effective in the past, or you may not want to get an intravenous line. If you have received a medication for migraine in the past and have experienced side effects from this medication, you should make this known. It will be important to make your care provider aware of these details, so that they can choose a treatment option that you are comfortable with and that is safe.
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- Orr SL, Aubé M, Becker WJ, et al. Canadian Headache Society
- systematic review and recommendations on the treatment of migraine pain in emergency settings. Cephalalgia 2015;35(3):271–84.
- Colman I, Rothney A, Wright S, Zilkalns B, Rowe BH. Use of narcotic analgesics in the emergency department treatment of migraine headache. Neurology 2004;62(10):1695–700.
- Sumamo Schellenberg E, Dryden DM, Pasichnyk D, Ha C, Vandermeer B, Friedman BW, Colman I, Rowe BH. Acute Migraine Treatment in Emergency Settings. Comparative Effectiveness Review No. 84. (Prepared by the University of Alberta Evidence-based Practice Center under Contract No. 290-2007-10021-I.) AHRQ Publication No. 12(13)- EHC142-EF. Rockville, MD: Agency for Healthcare Research and Quality. November 2012
- D’Amico D, Moschiano F, Bussone G. Early treatment of migraine attacks with triptans: a strategy to enhance outcomes and patient satisfaction? Expert Rev Neurother 2006;6(7):1087–97.
Strategies to Avoid Emergency Department Visits for Migraine
By: Juliana VanderPluym, MD, FRCPC
The best strategy to avoid Emergency Department (ED) visits for migraine is to avoid having a migraine in the first place. There are two main components to trying to avoid migraines: 1. Using preventive strategies and 2. Navigating triggers.
All patients with migraine should follow the “SEEDS” strategy for success in headache management1 (see diagram). The “SEEDS” strategy is comprised of lifestyle modifications that can reduce the chances of having migraine attacks. These strategies are an integral part of managing migraines and should not be overlooked even when medications are being used as part of the treatment plan.
When migraines are not controlled with lifestyle measures alone, then preventive medications may be used to help reduce the frequency and severity of headaches. If you are experiencing more than 4 headaches per month, it is important to talk to your physician about whether you should be on a daily preventive medication. For individuals who are already on daily preventive medications, it is important to take them as prescribed, as they are unlikely to work if they are not taken consistently. Sometimes people stop taking preventive medications because of perceived side effects or because they feel that they are not effective. If either of these scenarios occurs, it is best to talk to your physician prior to stopping the medication so that they can discuss alternative treatment options with you.
A variety of migraine triggers exist; some are within our control (such as food, hunger, alcohol, too much or too little sleep, physical exertion, odors) and others are outside of our control (such as weather). Keeping a headache diary can help identify potential migraine triggers. However, not all individuals with migraine have triggers. If you do have triggers, try to reduce your exposure to them while at the same time remembering that it is a balance between what you can and cannot avoid, and be careful not put undue stress on yourself while trying to avoid triggers.
Unfortunately, not all migraines are avoidable. Identifying symptoms of migraine early is important so that at-home treatment strategies can be instituted as quickly as possible (see section entitled “At-home treatment strategies to try prior to visiting the emergency department”). Also, it is useful to have a discussion with your physician about alternative resources in your community, such as infusion centers, that can be used for treating migraine outside of the ED when your at-home treatment strategies don’t work.
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