Evidence-Based Emergency Department Management of Migraine and Other Primary Headaches (Pharmacology CME and Pain Management CME)

Table of Contents

 

About This Issue

Primary headaches can cause significant pain, suffering, and lost productivity, and patients often seek relief in the ED. Emergency clinicians must be aware of advances in novel medications, alternative treatments such as nerve blocks, and evidence-based strategies to prevent rebound headaches and medication overuse headache. In this issue, you will learn:

The questions that should be asked to rule out dangerous secondary causes of headache.

When imaging studies are needed, and when they are not.

Why IV antidopaminergic agents are considered first-line therapy for headache in the ED, and how to minimize potential side effects.

What role triptans may (or may not) play in ED management of headache.

What the current evidence is on the novel oral migraine medications: serotonin 5-HT1F receptor agonist and CGRP antagonists (“gepants”).

How and when to perform greater occipital nerve block or sphenopalatine ganglion block to relieve headache.

How to recognize and treat patients with medication overuse headache.

The latest evidence on treating patients with cluster headache.

Using corticosteroids to help prevent postdrome rebound headache.

1. About This Issue
2. Abstract
3. Case Presentations
4. Introduction
5. Critical Appraisal of the Literature
6. Etiology And Pathophysiology
   1. Tension-Type Headache
   2. Migraine
   3. Cluster Headache
   4. Medication Overuse Headache
7. Differential Diagnosis
   1. Episodic Headaches
   2. Chronic Headaches
8. Prehospital Care
9. Emergency Department Evaluation
   1. History
   2. Physical Examination
10. Diagnostic Studies
    1. Laboratory Studies
    2. Clinical Decision Rules
    3. Imaging Studies
       1. Limitations of Head Computed Tomography
11. Treatment
    1. Intravenous Antidopaminergic Antiemetics
    2. Dexamethasone
    3. Dihydroergotamine
    4. Triptans
    5. Novel Oral Migraine Medications
       1. 5-HT1F Receptor Agonist
       2. Anticalcitonin Gene-Related Peptide Medications
    6. Opioids
    7. Nerve Blocks
       1. Greater Occipital Nerve Block
       2. Sphenopalatine Ganglion Block
12. Special Populations
    1. Pediatric Patients
    2. Older Patients
    3. Pregnant Patients
    4. Patients With Cluster Headaches
       1. Nerve Blocks for Cluster Headache
       2. Other Treatments for Cluster Headaches
    5. Patients With Medication Overuse Headache
13. Controversies and Cutting Edge
    1. Development of Novel Drug Treatments
    2. Diagnosis of Headache Disorder
14. Disposition
15. Summary
16. Risk Management Pitfalls for Managing Primary Headaches in the Emergency Department
17. Time- And Cost-Effective Strategies
18. Case Conclusions
19. Clinical Pathway for Managing Primary Headaches in the Emergency Department
20. Tables and Figures
21. References

Abstract

Headache is the fifth most common presenting chief complaint in emergency departments, and it is vital to quickly rule out life-threatening secondary causes. Though there are many medications, new and old, that can be used to treat primary headache, the evidence for their effectiveness can be conflicting. This review describes the pathology, workup, and treatment for migraine and other primary headaches based on the best available evidence, including novel medications, nerve blocks, and strategies for preventing postdrome recurrence. Other headache disorders, including cluster headache, medication overuse headache, and chronic migraine are also reviewed.

Case Presentations

A 36-year 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 ED about once a year for refractory events. This headache began gradually 12 hours prior and, despite use of 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 man with a history of infrequent, episodic migraine 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 were occurring about once per week and responding 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 ED that might help…

A 53-year woman with migraine presents with a severe headache. She reports a history of 4 headache days per week, which has been going on for more than 10 years...

• She typically manages her headaches with oral eletriptan, naproxen, acetaminophen, Excedrin^® migraine, and a combination butalbital/acetaminophen/caffeine drug. In the past she has been treated with botulinum toxin injections and oral topiramate. She is typically forced to present to an ED 3 times per year for management of severe headache, but because she has previously experienced dystonic reactions, she is reluctant to receive an antidopaminergic medication.
• As you begin your evaluation, she says, “Doc, just give me my Dilaudid.” You can see she is in severe pain, but you wonder whether giving opioids is the best option in her care…

How would you manage these patients? Subscribe for evidence-based best practices and to discover the outcomes.

Clinical Pathway for Managing Primary Headaches in the Emergency Department

Subscribe to access the complete flowchart to guide your clinical decision making.

Tables and Figures

Subscribe for full access to all Tables and Figures.

Key References

Following are the most informative references cited in this paper, as determined by the authors.

9. * Loder E. Triptan therapy in migraine. N Engl J Med. 2010;363(1):63-70. (Review) DOI: 10.1056/NEJMct0910887

17. * Edlow JA, Panagos PD, Godwin SA, et al. Clinical Policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with acute headache. Ann Emerg Med. 2008;52(4):407-436. (Research support, non-United States government) DOI: 10.1016/j.jen.2008.12.009

21. * Friedman BW. Managing migraine. Ann Emerg Med. 2017;69(2):202-207. (Review) DOI: 10.1016/j.annemergmed.2016.06.023

29. * Orr SL, Friedman BW, Christie S, et al. Management of adults with acute migraine in the emergency department: the American Headache Society evidence assessment of parenteral pharmacotherapies. Headache. 2016;56(6):911-940. (Review) DOI: 10.1111/head.12835

50. * Patel D, Yadav K, Taljaard M, et al. Effectiveness of peripheral nerve blocks for the treatment of primary headache disorders: a systematic review and meta-analysis. Ann Emerg Med. 2022;79(3):251-261. (Meta-analysis; 9 studies) DOI: 10.1016/j.annemergmed.2021.08.007

61. * Robbins MS, Starling AJ, Pringsheim TM, et al. Treatment of cluster headache: the American Headache Society evidence-based guidelines. Headache. 2016;56(7):1093-1106. (Review) DOI: 10.1111/head.12866

62. * Obermann M, Nagel S, Ose C, et al. Safety and efficacy of prednisone versus placebo in short-term prevention of episodic cluster headache: a multicentre, double-blind, randomised controlled trial. Lancet Neurol. 2021;20(1):29-37. (Randomized controlled trial; 118 patients) DOI: 10.1016/S1474-4422(20)30363-X

Subscribe to get the full list of 73 references and see how the authors distilled all of the evidence into a concise, clinically relevant, practical resource.

Keywords: headache, migraine, postdrome, cluster, medication overuse, triptan, oxygen, antidopaminergic, corticosteroid, dihydroergotamine, anti-CGRP, gepants, nerve block