ED Pathway for the Evaluation/Treatment of the Patient with Migraine Headache
  • Headache with altered mental status and/or focal neurologic findings
    • Care as indicated
    • Consider Stroke Protocol
    • Imaging, Neurology Consult
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PO/IV Therapy
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Reassess
45 minutes
Significant HA Persists
Valproic Acid

Reassess 45 minutes

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Headache Improved

Rebound Headache
Recurrence of symptoms in 24-48 hours

Consider Methylprednisolone, discharge with steroid taper

Valproic Acid
Most patients with acute headache treated with Valproic Acid do not need Valproic Acid after discharge

Consult Neurology if considering treatment with Valproic Acid after discharge

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Significant
HA Persists

Neurology consult
for admission
Criteria
Medications
Education
Healthy Habits
Follow-up
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IV Therapy Immediate Neurology Consult
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Reassess
45 minutes
Significant HA Persists
  • Follow Neurology recommendations
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Reassess
45 minutes
Headache Improved
  • Follow Neurology Recommendations
Reassess 45 minutes after each intervention
Assessment includes:
  • Vital Signs, brief neuro exam
  • Pain Scale
  • Resolution of Associated symptoms
Migraine HA Medications
MedicationDoseRouteMax
Metoclopramide0.2 mg/kgIV/PO< 12 yrs: 10 mg
≥ 12 yrs: 20 mg
Ketorolac0.5 mg/kgIV30 mg
Ibuprofen10 mg/kgPO800 mg
Valproic Acid15 mg/kgIV1 gram
Methylprednisolone2 mg/kgIV200 mg
Ranitidine1 mg/kgIV50 mg
Ok to give IV Ketorolac even if patient has taken oral NSAID within the past 6 hours since it is escalation of care.
Posted: February 2010
Revised: October 2011, April 2015
Authors: N. Hughes, MD; C. Szpreka, MD; J. Lavelle, MD, C. Jacobstein, MD, D. Glatts, RN, D. Younkin, MD,
N. Abend, MD