Skip to main content Accessibility help
  • Print publication year: 2017
  • Online publication date: October 2017

7 - The Migraine Patient in the Emergency Department



Migraine is the most common primary headache disorder seen in the emergency department (ED). Patients with migraine present to the ED for a variety of reasons, including intolerable pain severity, failure of at-home treatment strategies, and debilitating associated symptoms. The diagnosis and management of migraine in the ED can be challenging. In this chapter, the epidemiology of migraine in the ED will be reviewed. A detailed and practical approach to the diagnosis and management of migraine in the ED will be outlined, followed by a discussion of discharge planning issues in this population.

1.Smitherman, TA, Burch, R, Sheikh, H, Loder, E. The prevalence, impact, and treatment of migraine and severe headaches in the United States: a review of statistics from national surveillance studies. Headache. 2013;53(3):427–36.
2.Cooke, LJ, Becker, WJ. Migraine prevalence, treatment and impact: the Canadian women and migraine study. Can J Neurol Sci. 2010;37(5):580–7.
3.Stovner, LJ, Andree, C. Prevalence of headache in Europe: a review for the Eurolight project. J Headache Pain. 2010;11(4):289–99.
4.Vos, T, Flaxman, AD, Naghavi, M, et al. Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380(9859):2163–96.
5.Lucado, J, Paez, K, Elixhauser, A. Headaches in US Hospitals and Emergency Departments, 2008: Statistical Brief #111. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. 2011;24:112.
6.Friedman, BW, Hochberg, ML, Esses, D, et al. Applying the International Classification of Headache Disorders to the emergency department: an assessment of reproducibility and the frequency with which a unique diagnosis can be assigned to every acute headache presentation. Ann Emerg Med. 2007;49(4):409–19.
7.Marco, CA, Kanitz, W, Jolly, M. Pain scores among emergency department (ED) patients: comparison by ED diagnosis. J Emerg Med. 2013;44(1):4652.
8.Lafata, JE, Moon, C, Leotta, C, et al. The medical care utilization and costs associated with migraine headache. J Gen Intern Med. 2004;19(10):1005–12.
9.Bloudek, LM, Stokes, M, Buse, DC, et al. Cost of healthcare for patients with migraine in five European countries: results from the International Burden of Migraine Study (IBMS). J Headache Pain. 2012;13(5):361–78.
10.Sanderson, JC, Devine, EB, Lipton, RB, et al. Headache-related health resource utilisation in chronic and episodic migraine across six countries. J Neurol Neurosurg Psychiatry. 2013;84(12):1309–17.
11.Gerth, WC, Carides, GW, Dasbach, EJ, Visser, WH, Santanello, NC. The multinational impact of migraine symptoms on healthcare utilisation and work loss. Pharmacoeconomics. 2001;19(2):197206.
12.Friedman, BW, Serrano, D, Reed, M, Diamond, M, Lipton, RB. Use of the emergency department for severe headache: a population-based study. Headache. 2009;49(1):2130.
13.Munakata, J, Hazard, E, Serrano, D, et al. Economic burden of transformed migraine: results from the American Migraine Prevalence and Prevention (AMPP) Study. Headache. 2009;49(4):498508.
14.Buse, DC, Pearlman, SH, Reed, ML, et al. Opioid use and dependence among persons with migraine: results of the AMPP study. Headache. 2012;52(1):1836.
15.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.
16.Lainez, MJA. The effect of migraine prophylaxis on migraine-related resource use and productivity. CNS Drugs. 2009;23(9):727–38.
17.Lane, P, Nituica, C, Sorondo, B. Headache patients: who does not come to the emergency department? Acad Emerg Med. 2003;10:528.
18.Chan, BT, Ovens, HJ. Chronic migraineurs: an important subgroup of patients who visit emergency departments frequently. Ann Emerg Med. 2004;43(2):238–42.
19.Wilper, A, Woolhandler, S, Himmelstein, D, Nardin, R. Impact of insurance status on migraine care in the United States: a population-based study. Neurology. 2010;74(15):1178–83.
20.Minen, MT, Tanev, K. Influence of psychiatric comorbidities in migraineurs in the emergency department. Gen Hosp Psychiatry. 2014;36(5):533–8.
21.Badia, X, Magaz, S, Gutierrez, L, Galvan, J. The burden of migraine in Spain: beyond direct costs. Pharmacoeconomics. 2004;22(9):591603.
22.Edmeads, J, Mackell, JA. The economic impact of migraine: an analysis of direct and indirect costs. Headache. 2002;42(6):501–9.
23.Friedman, D, Feldon, S, Holloway, R, Fisher, S. Utilization, diagnosis, treatment and cost of migraine treatment in the emergency department. Headache. 2009;49(8):1163–73.
24.Insinga, RP, Ng-Mak, DS, Hanson, ME. Costs associated with outpatient, emergency room and inpatient care for migraine in the USA. Cephalalgia. 2011;31(15):1570–5.
25.Stokes, M, Becker, WJ, Lipton, RB, et al. Cost of health care among patients with chronic and episodic migraine in Canada and the USA: results from the International Burden of Migraine Study (IBMS). Headache. 2011;51(7):1058–77.
26.Minen, MT, Loder, E, Friedman, B. Factors associated with emergency department visits for migraine: an observational study. Headache. 2014;54(10):1611–18.
27.Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia. 2013;33(9):629808.
28.Trottier, ED, Bailey, B, Lucas, N, Lortie, A. Diagnosis of migraine in the pediatric emergency department. Pediatr Neurol. 2013;49(1):40–5.
29.Lipton, RB, Dodick, D, Sadovsky, R, et al. A self-administered screener for migraine in primary care: the ID Migraine validation study. Neurology. 2003;61(3):375–82.
30.Mostardini, C, d’Agostino, VC, Dugoni, DE, Cerbo, R. A possible role of ID-Migraine in the emergency department: study of an emergency department out-patient population. Cephalalgia. 2009;29(12):1326–30.
31.Rasmussen, B, Jensen, R, Schroll, M, Olesen, J. Epidemiology of headache in a general population: a prevalence study. J Clin Epidemiol. 1991;44(11):1147–57.
32.Forsyth, PA, Posner, JB. Headaches in patients with brain tumors: a study of 111 patients. Neurology. 1993;43(9):1678–83.
33.Marcus, D. Migraine and tension-type headaches: the questionable validity of current classification systems. Clin J Pain. 1992;8:2836.
34.Lipton, RB, Cady, RK, Stewart, WF, Wilks, K, Hall, C. Diagnostic lessons from the spectrum study. Neurology. 2002;58(9 Suppl. 6):S27–31.
35.Spierings, ELH, Ranke, AH, Honkoop, PC. Precipitating and aggravating factors of migraine versus tension-type headache. Headache. 2001;41(6):554–8.
36.Bendtsen, L, Evers, S, Linde, M, et al. EFNS guideline on the treatment of tension-type headache: report of an EFNS task force. Eur J Neurol. 2010;17(11):1318–25.
37.Weinman, D, Nicastro, O, Akala, O, Friedman, BW. Parenteral treatment of episodic tension-type headache: a systematic review. Headache. 2014;54(2):260–8.
38.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.
39.Friedman, BW, Greenwald, P, Bania, TC, et al. Randomized trial of IV dexamethasone for acute migraine in the emergency department. Neurology. 2007;69(22):2038–44.
40.Tfelt-Hansen, P, Pascual, J, Ramadan, N, et al. Guidelines for controlled trials of drugs in migraine: third edition. A guide for investigators. Cephalalgia. 2012;32(1):638.
41.Friedman, B. Intravenous fluids for migraine: a post-hoc analysis of clinical trial data [abstract]. Headache. 2015;55(Suppl. 3):127–87.
42.Colman, I, Brown, MD, Innes, GD, et al. Parenteral metoclopramide for acute migraine: meta-analysis of randomised controlled trials. BMJ. 2004;329(7479):1369–72.
43.Sumamo Schellenberg, E, Dryden, DM, Pasichnyk, D, et al. Acute Migraine Treatment in Emergency Settings. Comparative Effectiveness Review No. 84. Rockville, MD: Agency for Healthcare Research and Quality; 2012.
44.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.
45.Taggart, E, Doran, S, Kokotillo, A, et al. Ketorolac in the treatment of acute migraine: a systematic review. Headache. 2013;53(2):277–87.
46.Friedman, BW, Cabral, L, Adewunmi, V, et al. Diphenhydramine as adjuvant therapy for acute migraine: an emergency department-based randomized clinical trial. Ann Emerg Med. 2016;67(1):32–9.
47.Friedman, BW, Corbo, J, Lipton, RB, et al. A trial of metoclopramide vs sumatriptan for the emergency department treatment of migraines. Neurology. 2005;64(3):463–8.
48.Talabi, S, Masoumi, B, Azizkhani, R, Esmailian, M. Metoclopramide versus sumatriptan for treatment of migraine headache: a randomized clinical trial. J Res Med Sci. 2013;18(8):695–8.
49.Colman, I, Brown, MD, Innes, GD, et al. Parenteral dihydroergotamine for acute migraine headache: a systematic review of the literature. Ann Emerg Med. 2005;45(4):393401.
50.Winner, P, Ricalde, O, Le Force, B, Saper, J, Margul, B. A double-blind study of subcutaneous dihydroergotamine vs subcutaneous sumatriptan in the treatment of acute migraine. Arch Neurol. 1996;53:180–4.
51.Vinson, DR. Treatment patterns of isolated benign headache in US emergency departments. Ann Emerg Med. 2002;39(3):215–22.
52.Friedman, BW, Kapoor, A, Friedman, MS, Hochberg, ML, Rowe, BH. The relative efficacy of meperidine for the treatment of acute migraine: a meta-analysis of randomized controlled trials. Ann Emerg Med. 2008;52(6):705–13.
53.Leinisch, E, Evers, S, Kaempfe, N, et al. Evaluation of the efficacy of intravenous acetaminophen in the treatment of acute migraine attacks: a double-blind, placebo-controlled parallel group multicenter study. Pain. 2005;117(3):396400.
54.Turkcuer, I, Serinken, M, Eken, C, et al. Intravenous paracetamol versus dexketoprofen versus morphine in acute mechanical low back pain in the emergency department: a randomised double-blind controlled trial. EMJ. 2014;31(3):177–81.
55.Zhang, A, Jiang, T, Luo, Y, et al. Efficacy of intravenous propacetamol hydrochloride in the treatment of an acute attack of migraine. Eur J Intern Med. 2014;25(7):629–32.
56.Leniger, T, Pageler, L, Stude, P, Diener, HC, Limmroth, V. Comparison of intravenous valproate with intravenous lysine-acetylsalicylic acid in acute migraine attacks. Headache. 2005;45(1):42–6.
57.Foroughipour, M, Ghandehari, K, Khazaei, M, et al. Randomized clinical trial of intravenous valproate (Orifil) and dexamethasone in patients with migraine disorder. Iran J Med Sci. 2013;38(Suppl. 2):150–5.
58.Friedman, BW, Garber, L, Yoon, A, et al. Randomized trial of IV valproate vs metoclopramide vs ketorolac for acute migraine. Neurology. 2014;82(11):976–83.
59.Moshtaghion, H, Heiranizadeh, N, Rahimdel, A, et al. The efficacy of propofol vs. subcutaneous sumatriptan for treatment of acute migraine headaches in the emergency department: a double-blinded clinical trial. Pain Pract. 2014;15(8)701–5.
60.Soleimanpour, H, Ghafouri, RR, Taheraghdam, A, et al. Effectiveness of intravenous dexamethasone versus propofol for pain relief in the migraine headache: a prospective double blind randomized clinical trial. BMC Neurol. 2012;12:114.
61.Rowe, BH, Colman, I, Edmonds, ML, et al. Randomized controlled trial of intravenous dexamethasone to prevent relapse in acute migraine headache. Headache. 2008;48(3):333–40.
62.Colman, I, Friedman, BW, Brown, MD, et al. Parenteral dexamethasone for acute severe migraine headache: meta-analysis of randomised controlled trials for preventing recurrence. BMJ. 2008;336(7657):1359–61.