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New Acute Migraine Guidelines for EDs Recommend Using New Injectables, Avoiding Opioids

June 17, 2016

Adults who visit emergency departments (ED), who suffer from acute migraines, should be administered one of three new injectable drugs, according to new treatment guidelines. 

The new guidelines were developed by the American Headache Society in order to provide guidance on which injectable medications should be considered first-line treatment for adults who present to an ED with acute migraine.

The society compiled an panel of experts who searched the Medline, Embase, and Cochrane databases as well as the clinical trial registries from inception through 2015. The panel then rated the identified articles using the American Academy of Neurology risk of bias tool. Each medication’s likelihood of efficacy was determined by the panel, and recommendations were created based on efficacy, adverse events, availability of alternative therapies, and principles of medication action.

The panel’s search identified 68 unique, randomized, controlled trials in which 28 different injectable medications were utilized. Of the 68 trials, 19 were rated class one or low risk of bias. Addtionally, 21 were rated class two, higher risk of bias, and 28 were rated class three, highest risk of bias.

The medications metoclopramide, prochlorperazine, and sumatriptan had the highest level of evidence, with multiple class one studies supporting acute efficacy. All other trialed medications had lower evidence levels. Dexamethasone, which prevents headache recurrence, also had multiple class one supporting studies.

The guidelines authors concluded that intravenous metoclopramide, prochlorperazine, and sumatriptan should be offered to adults who are eligible and who present with acute migraine symptoms in the ED, and dexamethasone should be offered to eligible adults to prevent recurrence of headaches.

They also cautioned that injectable morphine and hydromorphone should be avoided as first-line therapy due to lack of evidence demonstrating efficacy as well as a heightened concern about sub-acute or long-term sequelae.


Orr S, Friedman B, Christie S, et al. Management of adults with acute migraine in the emergency department: the American Headache Society evidence assessment of parenteral pharmacotherapies [published online June 14, 2016]. Headache. doi:10.1111/head.12835.

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