Emergency Migraine Management and Patient Counseling in the ED

A recent guidance summary highlights specific parenteral strategies — notably IV prochlorperazine and greater occipital nerve block — for eligible adults presenting to the emergency department with acute migraine, prioritizing rapid symptom control and individualized risk assessment.

The update recommends immediate parenteral relief plus brief counseling on modifiable risks such as alcohol use to reduce early recurrence.

Parenteral options include prochlorperazine IV, metoclopramide IV, IV NSAIDs (eg, ketorolac), and greater occipital nerve block for selected patients. The report lists typical ED dosing ranges (prochlorperazine 5–10 mg IV; metoclopramide ≈10 mg IV; ketorolac 15–30 mg IV), but clinicians should verify exact doses against primary guidelines or prescribing information.

Monitoring and prompt recognition of adverse effects are essential. Dopamine‑antagonist antiemetics can cause akathisia or dystonic reactions—have IV diphenhydramine available for acute dystonia and a clear treatment plan. Observe for post‑treatment hypotension after parenteral analgesics and screen for cardiac risk when using agents that prolong the QT interval or may precipitate arrhythmia. Procedural nerve‑block safety requires informed consent, precise anatomic technique, strict aseptic technique, and post‑procedure observation to detect local or systemic complications. Structured monitoring and medication‑specific precautions reduce treatment‑related harm.

Risk assessment should focus on pregnancy, known cardiovascular disease, electrolyte abnormalities, recent substance use (including alcohol), and features suggestive of medication‑overuse headache. Avoid dopamine antagonists in patients with documented prolonged QT or other arrhythmia risk, avoid NSAIDs late in pregnancy, and favor non‑dopaminergic analgesic strategies when cardiac or QT risk is present. When pregnancy or other contraindications limit standard parenteral choices, select safer alternatives and arrange early outpatient follow‑up for prevention planning. Individualize selection to the patient’s risk profile.

Deliver brief, actionable counseling in the ED—one to two minutes is effective. Advise patients to limit or avoid alcohol as it can trigger attacks and increase frequency; recommend tracking triggers with a headache diary and sharing it at follow‑up. For frequent headaches, arrange outpatient evaluation for preventive strategies and cardiovascular‑risk review, and provide a specific referral or primary‑care follow‑up plan before discharge.

Key Takeaways:

• Adopt prochlorperazine IV and consider greater occipital nerve block as primary parenteral options for eligible adults with acute migraine in the ED.
• Use agent‑specific monitoring (watch for akathisia, hypotension, QT risk) and keep IV diphenhydramine available for acute dystonia.
• Deliver brief, actionable counseling on alcohol reduction and arrange outpatient follow‑up for preventive care.