Treatment of migraine in the emergency department

Migraine is defined as a severe, episodic, unilateral, throbbing headache accompanied by nausea, photophobia, visual symptoms, and neurological manifestations. The goal of acute migraine treatment is to ensure a prompt cessation of pain and associated symptoms and resumption of normal activity. Additional considerations include minimizing adverse effects and cost of therapy. As for all neurological patients, a careful history is the first and most critical step in diagnosis and management. For many years, NSAIDs and dihydroergotamine were the main medications used to treat migraine in the emergency setting. In 1993, sumatriptan was introduced as an effective medication to treat migraine. Since then a generation of medications mechanistically similar to sumatriptan have been introduced that show notable benefits in the treatment of migraine. Over the years, other treatments have been introduced including dexamethasone, magnesium, and metoclopramide. In this article, we review the best evidence regarding the acute treatment of migraine, describing major advances and the conventional drugs that remain as effective treatments.