What Will the ER Give Me for My Migraine?

Intravenous Migraine Medications in the Emergency Room

You Will Likely Get an Intravenous Medication in the ER
You Will Likely Get an Intravenous Medication in the ER. slobo/Vetta/Getty Images

Sometimes the pain of a migraine attack is so intense that it requires an emergency room visit. Or, in other cases, nausea and vomiting that accompany a migraine attack limit oral medication intake. In emergency rooms or urgent care centers, acute migraine attacks are often treated with intravenous medications. But which one is best?

One study in Neurology randomized 330 patients with an acute migraine attack to receive either 1g sodium valproate, 10mg Reglan (metoclopramide), or 30mg Toradol (ketorolac).

Sodium valproate is an anti-seizure medication that in its oral form is sometimes used to prevent migraines. In fact, the American Academy of Neurology concluded that the valproate products, divalproex sodium and sodium valproate, are effective (Level A drugs) in preventing migraines. This being said, it is important to note that valproate is contraindicated in pregnant women.

Reglan (Metoclopramide) is an anti-emetic or anti-nausea medication. It blocks dopamine receptors in the brain and primarily alleviates gastroparesis (when the emptying of gastric contents is delayed). It is commonly used as a single agent for treating migraines in emergency rooms. It can cause a feeling of restlessness.

Toradol (Ketorolac) is a NSAID with a rapid onset of action. Like Reglan, it is commonly used in emergency rooms to treat migraines. Remember, though, NSAIDs do have several potential adverse effects and should be avoided by some individuals, particularly those with a history of stomach bleeding, kidney disease, and/or heart disease.

What Did this Migraine Study Show?

In the study, all of the patients reported an initial migraine pain score of 7 or more on a 0 to 10 point scale, and the majority were not taking a preventive migraine therapy.

After one hour of receiving one of the three medications mentioned above, those who received sodium valproate improved by an average score of 2.8 whereas those who received Reglan and Toradol improved by an average of 4.7 and 3.9 points, respectively.

The results of the study also revealed that the recipients of sodium valproate required more rescue migraine medications (69 percent) compared with those who received metoclopramide (33 percent) and ketorolac (52 percent). A rescue migraine medication

Finally, a greater number of recipients of Reglan preferred to receive this same medication at a future emergency room visit compared with the other two groups.

This all being said, at 24 hours after initial medication administration, sustained headache relief was low in all three groups: sodium valproate (4 percent), Reglan (11 percent), and Toradol (16 percent)—not too great of a conclusion.

What Does This All Mean?

  • Reglan and Toradol may be preferred over sodium valproate as an intravenous medication for migraine attacks in the emergency room.
  • Reglan may be a preferred medication among patients who go to the ER for a migraine—although this is not a hard and fast rule.
  • The downside revealed here is that majority of the subjects did not have sustained relief of their head pain. This means we need better therapies to provide pain relief for migraineurs during an acute, severe attack.

A caveat of the study that should be mentioned is that the majority of the participants were not taking a migraine preventive therapy.

This makes it difficult to generalize the results to those with more severe and/or chronic migraine (who are likely taking a preventive medication).

Another point to bring up is that these three intravenous medications are not the only ones used to treat severe, acute migraine attacks in the emergency room. 

Another option for migraine therapy in the ER is subcutaneous sumatriptan (a triptan given as an injection into your fatty tissue).  Other types of antiemetics like Compazine (prochlorperazine) may be given, often along with Benadryl (diphenhydramine) to prevent side effects of antiemetics, like restlessness and dystonia.

Dihydroergotamine (DHE) can also be given in the emergency room and can be administered as a nasal spray, intravenously, or intramuscularly. DHE can cause nausea, so an antiemetic is generally given beforehand to prevent this. 

Finally, some ER doctors also give a steroid called dexamethasone with one of the above-mentioned migraine therapies—the theory being that is can help reduce the chance that the person's headache will return early. Hydration with IV fluids is also a big part of treating migraines in the emergency room, especially if a person has nausea and vomiting. 

A Word From Verywell

If you end up going to the ER for an acute migraine attack, you may receive an intravenous medication (or an injection, if your doctor gives you sumatriptan). In the end, what the doctor gives you is an individualized decision, based on your unique health history.

Sources:

Bajwa ZH, Smith JH. (February 2017). Acute treatment of migraine in adults. In: UpToDate, Swanson JW (Ed), UpToDate, Waltham, MA.

Gilmore B, Michael M. Treatment of Acute Migraine Headache. Am Fam Physician. 2011 Feb 1;83(3):271-280.

Friedman BW et al. Randomized trial of IV valproate vs metoclopramide vs ketorolac for acute migraine. Neurology. 2014 Mar 18;82(11):976-83.

Kostic MA, Gutierrez FJ, Rieg TS, Moore TS, Gendron RT. A prospective, randomized trial of intravenous prochlorperazine versus subcutaneous sumatriptan in acute migraine therapy in the emergency department. Ann Emerg Med. 2010 Jul;56(1):1-6.

Silberstein SD et al. Evidence-based guideline update: pharmacologic treatment for episodic migraine prevention in adults: report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society. Neurology 2012; 78:1337.

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