Migraine is a recurrent neurologic disorder affecting ~12% of the population (17% of women, 6% of men), characterized by unilateral, pulsating headache lasting 4–72 hours with associated nausea, photophobia, phonophobia, and aggravation by physical activity. [1-2] It is the second leading cause of disability worldwide. [2] The following is a comprehensive clinical summary organized for emergency medicine and primary care practice.
1. History
- Characterize the headache: location (unilateral vs. bilateral — ~40% report bilateral pain), quality (pulsating/throbbing), intensity (moderate to severe), duration (4–72 hours untreated) [1][3]
- Timing and triggers: frequency, time of day, relationship to menstrual cycle (perimenstrual attacks are common in women), sleep patterns, stress, weather changes, skipped meals [1][4]
- Associated symptoms: nausea/vomiting, photophobia, phonophobia, osmophobia (intolerance to smells), movement worsening pain [1][5]
- Aura: visual (scintillations, scotoma), sensory (paresthesias), or speech disturbance developing over 5–60 minutes, typically preceding headache by ≤60 minutes [1-2]
- Premonitory symptoms: mood changes, neck pain, food cravings, polyuria, yawning (hours before headache) [1]
- Postdrome: fatigue, difficulty concentrating after headache resolves [1]
- Important negatives: thunderclap onset, fever, weight loss, progressive worsening, new onset after age 50, positional component, trauma history [1-2]
2. Alarm Features
Use the SNNOOP10 mnemonic to screen for secondary headache: [5-6]
- Thunderclap headache (maximal intensity within seconds to minutes) — >40% pretest probability for serious intracranial pathology (SAH, RCVS) [1][5]
- Fever with meningeal signs (neck stiffness, Kernig/Brudzinski signs)
- Papilledema with focal neurologic deficits or impaired consciousness
- New onset after age 50 — consider giant cell arteritis, neoplasm [1][7]
- Progressive or pattern-change headache — mass lesion, intracranial disorder
- Neurologic deficits not consistent with typical aura (sudden onset, persistent, motor weakness)
- Positional headache — intracranial hypo/hypertension
- Pregnancy/postpartum — preeclampsia, cerebral venous sinus thrombosis, arterial dissection [8]
- Immunosuppression or cancer history — opportunistic infection, metastasis
- Posttraumatic onset — subdural hematoma
Any of these warrant emergent evaluation with neuroimaging ± lumbar puncture. [5]
3. Medications
Acute Treatment (Outpatient) — per the 2025 ACP guideline: [9]
- First-line: NSAIDs (ibuprofen 400 mg, naproxen 550 mg, aspirin 500 mg) or acetaminophen 1000 mg for mild-moderate attacks [1]
- Combination therapy (greatest net benefit): sumatriptan + naproxen > triptan monotherapy > NSAID monotherapy [9]
- Triptans for moderate-severe attacks: rizatriptan 10 mg, eletriptan 40 mg, sumatriptan 50–100 mg PO or 6 mg SC [1]
- Gepants (CGRP antagonists): ubrogepant, rimegepant, zavegepant (nasal) — for triptan failures/contraindications [10-11]
- Lasmiditan (ditan): alternative for patients with cardiovascular contraindications to triptans [11]
ED Parenteral Treatment — per the 2025 AHS guideline: [12]
- Level A – Must Offer: prochlorperazine 10–12.5 mg IV; greater occipital nerve block (GONB)
- Level B – Should Offer: metoclopramide 10 mg IV, ketorolac IV, sumatriptan 6 mg SC, supraorbital nerve block
- Level C – May Offer: chlorpromazine 12.5–25 mg IV, dexamethasone IV (for recurrence prevention), valproate IV
- Level A – Must NOT Offer: hydromorphone IV
- Level C – Should NOT Offer: IV acetaminophen (for pain relief)
- Give diphenhydramine 25–50 mg IV with dopamine antagonists to prevent akathisia/EPS [13]
Medications to Avoid
- Opioids and barbiturate combinations — risk of dependency, medication overuse headache, and inferior efficacy [1][12]
- Triptans/ergots contraindicated in CAD, stroke, PVD, uncontrolled cardiovascular risk factors [1][14]
- Limit acute medication use to <10 days/month (triptans, ergots, opioids) or <15 days/month (NSAIDs, acetaminophen) to prevent medication overuse headache [1]
Preventive Medications — indicated when ≥6 headache days/month, ≥4 days with impairment, or ≥3 days with severe impairment: [1]
- First-line oral: propranolol 120–160 mg, metoprolol 50–200 mg, topiramate 100 mg, divalproex/valproate 500–1000 mg [4]
- CGRP-targeted therapies: erenumab, fremanezumab, galcanezumab (monthly SC injections); eptinezumab (quarterly IV); atogepant, rimegepant (oral daily) [4][10]
- Second-line: amitriptyline 25–50 mg, venlafaxine 75–150 mg [4]
- Chronic migraine: onabotulinumtoxinA 155 U every 12 weeks (FDA-approved for ≥15 headache days/month) [4][10]
- Supplements: magnesium 400–800 mg/day, riboflavin 400 mg/day, CoQ10 300 mg/day [1][15]
The following figure compares pain freedom at 2 hours across acute migraine treatments:
4. Diet
- Common dietary triggers: alcohol (especially red wine), excessive caffeine (≥3 servings/day), aged cheeses, processed meats, chocolate, MSG — though evidence for individual food triggers is weak and highly individual [4][16-17]
- Hydration: increased water intake is associated with reduced headache frequency; dehydration is a recognized trigger [4][18]
- Dietary patterns with evidence: DASH diet and ketogenic diet have strong evidence for reducing migraine frequency and severity [16][19]
- Omega-3 fatty acids: increasing dietary n-3 fatty acids and lowering linoleic acid reduced headache frequency in a controlled trial [16]
- Elimination diets: limited evidence; should be personalized rather than broadly restrictive [16][20]
- Caffeine: bidirectional relationship — can treat acute attacks but excessive or irregular use may trigger attacks; abrupt withdrawal is a known trigger [16][18]
- Weight management: higher BMI is associated with increased migraine frequency; weight loss (surgical or lifestyle) reduces headache frequency [16][21]
5. Review of Systems
- Neurologic: visual changes, paresthesias, speech difficulty, weakness, vertigo, tinnitus
- Psychiatric: depression, anxiety, sleep disturbance, panic attacks
- GI: nausea, vomiting, abdominal pain (abdominal migraine in children)
- Cardiovascular: chest pain, palpitations (screen for cardiovascular risk before prescribing triptans)
- ENT: nasal congestion, sinus pressure (commonly misdiagnosed as "sinus headache")
- Musculoskeletal: neck pain/stiffness (common premonitory and accompanying symptom)
- Endocrine: menstrual history, OCP/HRT use (estrogen withdrawal triggers migraine) [1]
- Sleep: insomnia, snoring, sleep apnea symptoms [1]
6. Collateral History and Family History
- Family history: migraine has a strong genetic component; first-degree relatives have 2–4× increased risk [22-23]
- Childhood precursors: motion sickness, episodic vertigo, cyclic vomiting, abdominal migraine [5]
- Psychiatric comorbidities in family: depression, anxiety, bipolar disorder [22]
- Social context: occupational impact, disability days, medication use patterns, substance use (caffeine, alcohol), stress levels
- Collateral from witnesses: behavior during attacks, confusion, speech changes (to differentiate from stroke/seizure)
7. Risk Factors
- Female sex (3:1 female-to-male ratio) [1]
- Age 20–50 years (peak prevalence) [1]
- Hormonal factors: menstruation, declining estrogen, OCP use [1]
- Psychiatric disorders: depression (~2.5× more common), anxiety, PTSD [21-22]
- Sleep disorders: insomnia, obstructive sleep apnea, restless legs syndrome [1][24]
- Obesity: associated with chronic migraine and migraine progression [1][21]
- Medication overuse: opioids, barbiturates, triptans >10 days/month, NSAIDs >15 days/month [1]
- Cardiovascular conditions: hypertension, hyperlipidemia (especially with aura) [21-22]
- Atopic conditions: asthma, allergies [24]
- Excessive caffeine intake, smoking, stress, poor sleep hygiene [1][25]
Risk factors for chronification (episodic → chronic migraine): medication overuse, allodynia, persistent nausea, obesity, sleep apnea, depression, anxiety, high attack frequency [1]
8. Differential Diagnosis
- Tension-type headache: bilateral, pressing/tightening, mild-moderate, no nausea/vomiting, not worsened by activity [5]
- Cluster headache: strictly unilateral, periorbital, severe, 15–180 min, with ipsilateral autonomic features (tearing, rhinorrhea, ptosis) [1]
- Medication overuse headache: ≥15 headache days/month with regular overuse of acute medications for >3 months [26]
- Subarachnoid hemorrhage: thunderclap onset, "worst headache of life," meningismus — cannot miss [1][5]
- Cerebral venous sinus thrombosis: progressive headache, papilledema, focal deficits, especially in pregnancy/postpartum [8]
- Giant cell arteritis (age >50): new temporal headache, jaw claudication, visual changes, elevated ESR/CRP [1][7]
- Intracranial mass: progressive headache, worse in morning, focal deficits, papilledema [5]
- Meningitis/encephalitis: fever, neck stiffness, altered mental status [5]
- TIA/stroke: sudden-onset focal deficits (maximal in <1 min), no gradual spread — distinguish from aura which develops gradually over minutes with positive symptoms (scintillations, paresthesias) [7]
- Idiopathic intracranial hypertension: daily headache, papilledema, pulsatile tinnitus, visual obscurations (young obese women) [5]
- Acute angle-closure glaucoma: eye pain, injection, blurred vision, halos [5]
9. Past Medical History
- Prior migraine history: age of onset, frequency trajectory, previous treatments and responses
- Medication overuse history: frequency of analgesic/triptan use
- Psychiatric history: depression, anxiety, bipolar disorder (affects preventive medication choice)
- Cardiovascular history: CAD, stroke, PVD (contraindications to triptans/ergots) [1]
- Seizure history: epilepsy is comorbid; topiramate/valproate may serve dual purpose [22][27]
- GI history: peptic ulcer disease (limits NSAID use)
- Pregnancy status: affects all treatment decisions [8]
- Surgical history: prior neurosurgical procedures, bariatric surgery
10. Physical Exam
- Vital signs: blood pressure (hypertensive emergency?), temperature (infection?), heart rate
- Neurologic exam (most critical — should be normal in migraine): [2-3]
- Cranial nerves (pupil asymmetry, visual fields, fundoscopy for papilledema)
- Motor strength, sensation, coordination, gait
- Deep tendon reflexes
- Head/neck: temporal artery tenderness (GCA), cervical range of motion, pericranial muscle tenderness
- Fundoscopic exam: papilledema (raised ICP), subhyaloid hemorrhage (SAH)
- Meningeal signs: neck stiffness, Kernig, Brudzinski (limited sensitivity)
- Eye exam: conjunctival injection, pupil changes (cluster headache, glaucoma)
- Allodynia testing: cutaneous sensitivity to light touch on scalp/face (marker of central sensitization and chronification risk) [1]
Key point: An abnormal neurologic exam in a patient with headache should prompt investigation for secondary causes. [2]
11. Lab Studies
- Routine labs are not indicated for typical migraine with normal exam [3]
- When indicated:
- CBC, CMP: systemic illness, infection
- ESR and CRP: if age >50 with new headache (giant cell arteritis) [1]
- Pregnancy test: all women of reproductive age (affects treatment and differential)
- TSH: thyroid disease is a migraine comorbidity
- Magnesium level: low magnesium may contribute to migraine; check before supplementation [28]
- Coagulation studies: if anticoagulated or concern for hemorrhage
- Lumbar puncture: if SAH suspected with negative CT, or concern for meningitis/IIH (measure opening pressure) [5]
12. Imaging
- Not indicated for stable primary headache with normal neurologic exam [5]
- Emergent NCCT head: thunderclap headache (within 6–12 hours of onset to rule out SAH), focal neurologic deficits, altered consciousness, papilledema [5]
- LP after negative CT: required to exclude SAH if clinical suspicion remains [5]
- MRI brain (preferred for non-emergent concerning features): pattern change, new neurologic symptoms, atypical presentation, age >50 with new headache, side-locked headache [5][7]
- CTA/MRA: if vascular pathology suspected (dissection, RCVS, venous sinus thrombosis)
- Important findings to look for: mass lesion, hemorrhage, venous thrombosis, Chiari malformation, white matter lesions
13. Special Tests
- POUND mnemonic (Pulsating, duration 4–72 hOurs, Unilateral, Nausea, Disabling): ≥4 features = high likelihood of migraine [5]
- ID Migraine screening tool (3 items): photophobia, nausea, activity limitation in past 3 months — 2 of 3 positive has 81% sensitivity, 75% specificity [5]
- ICHD-3 diagnostic criteria: [3][26]
- Greater occipital nerve block (GONB): both diagnostic and therapeutic; Level A recommendation in ED [12]
- Headache diary: essential for tracking frequency, triggers, medication use, and treatment response [16]
- MIDAS (Migraine Disability Assessment) or HIT-6: quantify disability and guide treatment decisions
14. ECG
- Not routinely indicated for migraine
- Obtain ECG before:
- Prescribing dopamine antagonists (QTc prolongation risk) [28]
- Starting triptans in patients with cardiovascular risk factors
- Migraine with aura is associated with increased long-term cardiovascular and cerebrovascular risk [1][22]
- Recognize: ST changes or arrhythmias that may suggest cardiac etiology of symptoms (especially if chest tightness accompanies "triptan sensation")
15. Assessment
- Diagnosis is clinical based on ICHD-3 criteria; no biomarkers exist [3][26]
- Severity stratification:
- Episodic migraine: <15 headache days/month (majority of patients)
- Chronic migraine: ≥15 headache days/month for ≥3 months, with migraine features on ≥8 days [1]
- Status migrainosus: debilitating migraine lasting >72 hours — requires aggressive treatment [13]
- Typical presentation: recurrent stereotyped attacks with normal interictal exam
- Atypical features requiring further workup: first/worst headache, aura >60 min, aura without headache (especially new onset >50), motor aura, brainstem aura [2][7]
- Complications: medication overuse headache (2.5% annual progression to chronic migraine), migrainous infarction (rare), persistent aura without infarction [1]
16. Treatment Plan
Initial Stabilization (ED)
- Dark, quiet room; IV access
- First-line: prochlorperazine 10 mg IV + diphenhydramine 25 mg IV [12]
- Adjuncts: IV fluids (especially if dehydrated/vomiting), ketorolac 15–30 mg IV [12]
- Recurrence prevention: dexamethasone 10 mg IV (single dose) [12][29]
- Refractory: GONB, sumatriptan 6 mg SC (if no dopamine antagonist contraindication), IV valproate, IV magnesium 1–2 g [28][30]
Outpatient Acute Treatment: [1][9][11]
- Mild-moderate: NSAID or acetaminophen ± caffeine
- Moderate-severe: triptan + NSAID (sumatriptan 50–100 mg + naproxen 500 mg) — greatest net benefit per 2025 ACP guideline
- Triptan failure/contraindication: gepant (ubrogepant 50–100 mg, rimegepant 75 mg) or lasmiditan 50–200 mg
- Treat early in the attack for best efficacy [1]
- Antiemetic PRN: ondansetron or metoclopramide for significant nausea
Preventive Treatment: [1-2][4]
- Initiate when meeting frequency/disability thresholds (see Section 3)
- Start low, titrate slowly; allow 6–8 weeks for adequate trial
- First-line: beta-blocker or topiramate (choose based on comorbidities — e.g., propranolol if concurrent anxiety/tremor; topiramate if obesity; amitriptyline if insomnia/depression)
- CGRP-targeted therapies for patients failing ≥2 oral preventives [1][4]
- Lifestyle optimization (SEEDS mnemonic): Sleep, Exercise, Eating, Diary, Stress management [4][16]
17. Disposition
Discharge criteria
- Pain adequately controlled
- Tolerating PO intake
- Normal neurologic exam
- No red flags identified
- Reliable follow-up arranged
Admission criteria
- Status migrainosus refractory to ED treatment [13]
- Intractable vomiting/dehydration
- Concern for secondary headache requiring inpatient workup
- Need for IV DHE protocol or continuous infusion therapies [28]
- Significant psychiatric comorbidity (suicidal ideation)
Specialist consultation triggers
- Diagnostic uncertainty
- Failure of ≥2 preventive medications
- Chronic migraine
- Atypical aura or hemiplegic migraine
- Medication overuse headache requiring supervised withdrawal
- Pregnancy with frequent migraine
18. Follow Up / Return Precautions
Follow-up timing
- After ED visit: PCP or headache specialist within 1–2 weeks
- After starting preventive therapy: reassess at 6–8 weeks [31]
- Chronic migraine: regular follow-up every 1–3 months
Return precautions (instruct patients to return immediately for):
- Thunderclap headache or "worst headache of life"
- Fever with stiff neck
- New neurologic symptoms: weakness, numbness, vision loss, confusion, speech difficulty
- Headache significantly different from usual pattern
- Persistent vomiting, inability to keep down fluids
- Worsening despite prescribed treatment
- Seizure
Patient counseling
- Migraine is a neurologic disease, not "just a headache"
- Maintain headache diary to identify triggers and track treatment response
- Avoid medication overuse (limit acute medications per guidelines)
- Expected recovery: most attacks resolve within 4–72 hours; postdrome fatigue is normal [1]
- Lifestyle modifications (regular sleep, meals, exercise, hydration, stress management) are as important as medications [4][16]
References
1. Diagnosis and Management of Headache: A Review. — Robbins MS. The Journal of the American Medical Association. 2021.
2. Migraine. — Ashina M. The New England Journal of Medicine. 2020.
3. Migraine: Disease Characterisation, Biomarkers, and Precision Medicine. — Ashina M, Terwindt GM, Al-Karagholi MA, et al. Lancet. 2021.
4. Migraine Headache Prophylaxis. — Moreland P, Gaffney B, Lanham JS. American Family Physician. 2025.
5. Acute Headache in Adults: A Diagnostic Approach. — Viera AJ, Antono B. American Family Physician. 2022.
6. Red and Orange Flags for Secondary Headaches in Clinical Practice: SNNOOP10 List. — Do TP, Remmers A, Schytz HW, et al. Neurology. 2019.
7. Migraine in Older Adults. — Hugger SS, Do TP, Ashina H, et al. The Lancet. Neurology. 2023.
8. Headaches in Pregnancy and Postpartum: ACOG Clinical Practice Guideline No. 3. — Committee on Clinical Practice Guidelines–Obstetrics Obstetrics and Gynecology. 2022.
9. Pharmacologic Treatments of Acute Episodic Migraine Headache in Outpatient Settings: A Clinical Guideline From the American College of Physicians. — Qaseem A, Tice JA, Etxeandia-Ikobaltzeta I, et al. Annals of Internal Medicine. 2025.
10. FDA Orange Book. — FDA Orange Book. 2026.
11. The American Headache Society Consensus Statement: Update on Integrating New Migraine Treatments Into Clinical Practice. — Ailani J, Burch RC, Robbins MS. Headache. 2021.
12. 2025 Guideline Update to Acute Treatment of Migraine for Adults in the Emergency Department: The American Headache Society Evidence Assessment of Parenteral Pharmacotherapies. — Robblee J, Minen MT, Friedman BW, et al. Headache. 2025.
13. Emergency Department and Inpatient Management of Headache in Adults. — Robblee J, Grimsrud KW. Current Neurology and Neuroscience Reports. 2020.
14. Acute Treatments for Episodic Migraine in Adults: A Systematic Review and Meta-analysis. — VanderPluym JH, Halker Singh RB, Urtecho M, et al. The Journal of the American Medical Association. 2021.
15. Magnesium Supplementation for Migraine Prophylaxis. — Rodriguez JP, Quarteroni E, Varela LB, Escobar Liquitay CM, Garegnani LI. The Cochrane Database of Systematic Reviews. 2025.
16. Lifestyle Factors and Migraine. — Seng EK, Martin PR, Houle TT. The Lancet. Neurology. 2022.
17. Diet and Migraine: What Is Proven?. — Gazerani P. Current Opinion in Neurology. 2023.
18. The Role of Avoiding Known Triggers, Embracing Protectors, and Adhering to Healthy Lifestyle Recommendations in Migraine Prophylaxis: Insights From a Prospective Cohort of 1125 People With Episodic Migraine. — Casanova A, Vives-Mestres M, Donoghue S, Mian A, Wöber C. Headache. 2023.
19. Effects of Dietary Interventions in Patients With Migraine: A Systematic Review. — Roldán-Ruiz A, Bertotti G, López-Moreno M. Nutrition Reviews. 2025.
20. Management of Headache (2023). — Jane Abanes PhD DNP MSN/Ed PMHCNS PMHNP-BC RN, Natasha M. Antonovich PharmD BCPS, Andrew C. Buelt DO, et al Department of Veterans Affairs. 2023.
21. Migraine: Epidemiology and Systems of Care. — Ashina M, Katsarava Z, Do TP, et al. Lancet. 2021.
22. Genetics of Migraine: Complexity, Implications, and Potential Clinical Applications. — Sutherland HG, Jenkins B, Griffiths LR. The Lancet. Neurology. 2024.
23. Migraine: A Review on Its History, Global Epidemiology, Risk Factors, and Comorbidities. — Amiri P, Kazeminasab S, Nejadghaderi SA, et al. Frontiers in Neurology. 2022.
24. Comorbidities as Risk Factors for Migraine Onset: A Systematic Review and Three-Level Meta-Analysis. — Terhart M, Overeem LH, Hong JB, Reuter U, Raffaelli B. European Journal of Neurology. 2025.
25. Prevalence and Association of Lifestyle and Medical-, Psychiatric-, and Pain-Related Comorbidities in Patients With Migraine: A Cross-Sectional Study. — Yin JH, Lin YK, Yang CP, et al. Headache. 2021.
26. Global, Regional, and National Burden of Headache Disorders, 1990-2023: A Systematic Analysis for the Global Burden of Disease Study 2023. — GBD 2023 Headache Collaborators. The Lancet. Neurology. 2025.
27. Neurological and Psychiatric Comorbidities of Migraine: Concepts and Future Perspectives. — Pelzer N, de Boer I, van den Maagdenberg AMJM, Terwindt GM. Cephalalgia : An International Journal of Headache. 2023.
28. Practice Advisory for Intravenous Management of Headache Disorders in Hospitalized Patients: A Review of the Evidence and Consensus Recommendations. — Hoydonckx Y, Feoktistov A, Amoozegar F, et al. Regional Anesthesia and Pain Medicine. 2026.
29. Management of Adults With Acute Migraine in the Emergency Department: The American Headache Society Evidence Assessment of Parenteral Pharmacotherapies. — Orr SL, Friedman BW, Christie S, et al. Headache. 2016.
30. Second-Line Interventions for Migraine in the Emergency Department: A Narrative Review. — Kazi F, Manyapu M, Fakherddine M, Mekuria K, Friedman BW. Headache. 2021.
31. Migraine: Integrated Approaches to Clinical Management and Emerging Treatments. — Ashina M, Buse DC, Ashina H, et al. Lancet. 2021.