Urgent Care Management of Migraine and Other Primary Headaches (Pain Management CME and Pharmacology CME)

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Delivery Method:	Online
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Publication Date: May 2025 (Volume 5, Number 4)

CME Credits: 4 AMA PRA Category 1 Credits™, 4 ACEP Category I credits, 4 AAFP Prescribed credits, and 4 AOA Category 2-B CME credits. CME expires 05/01/2028.

Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 2 Pain Management CME credits and 2 Pharmacology CME credits, subject to your state and institutional approval.

Authors

Peer Reviewer

Abstract

Headache is a common presentation in urgent care. Urgent care clinicians must be prepared to evaluate and manage primary headaches, as well as rapidly assess for potentially life-threatening secondary causes that require prompt referral or transfer. This review outlines the pathology, diagnostic approach, and treatment options for migraines and other primary headaches, using the best available evidence. It covers novel medications, nerve blocks, and strategies to prevent postdrome recurrence. Headache disorders are discussed, including cluster headaches, medication overuse headaches, and chronic migraines, along with treatment options for these disorders in the urgent care setting.

Case Presentations

A 36-year-old woman presents with a pounding left-sided headache associated with nausea that has persisted for 12 hours…

• She reports having similar headaches about twice monthly, and though they usually resolve with sumatriptan, she typically visits the urgent care about once a year for refractory events.
• This headache began gradually 12 hours prior and, despite taking oral sumatriptan 100 mg, ibuprofen 800 mg, and acetaminophen 1000 mg, it has not improved.
• Her physical examination is unremarkable, including normal vital signs, a normal fundoscopic and visual field examination, and a normal neurologic examination. A point-of-care urine pregnancy test is negative.
• You administer metoclopramide 10 mg IV and ketorolac 15 mg IV, but she reports only minimal relief.
• You wonder what your best next treatment option is…

A 45-year-old man with a history of infrequent, episodic migraines presents with an unremitting headache for 1 week…

• He reports an average of 3 severe headaches per year since high school, and they usually resolve completely with 10 mg oral rizatriptan.
• For the past 5 months, in association with increased stress at work, he reports an increase in headache frequency. At first, they occurred about once per week and responded to ibuprofen, but over the last month, he has had headaches nearly every day.
• Initially, he was getting relief with a combination of 10 mg oral rizatriptan once daily and 800 mg ibuprofen twice daily, but now these medications are not working at all. His headaches are associated with photophobia and phonophobia, and they are preventing him from functioning at work.
• His medical history is unremarkable, and the review of systems is otherwise normal. His physical examination, including vital signs, ophthalmologic, and neurologic examinations are normal.
• You wonder what you can offer him in the urgent care that might help…

A 24-year-old man presents to the urgent care with a dull headache that wraps around his head…

• He has never had a headache before.
• He notes that the headache started yesterday and says he hasn’t tried anything at home for his pain yet. He says anytime he presses on his head, the pain gets worse.
• His examination is notable for a band-like distribution of the headache. He has no photophobia or phonophobia. He denies any fevers, vision changes, or vomiting.
• You administer 1000 mg PO acetaminophen, and 30 minutes later he reports marked improvement in his symptoms.
• You wonder if he requires any additional workup while he is in your urgent care…

Accreditation:

EB Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.