ED Clinical Pathway for the Evaluation/Treatment of the Patient with Migraine Headache
Headache Red Flags
History of Rebound Headache
  • Consider 1 dose Methylprednisolone
  • Home prescription for Medrol Dosepak
  • Neurology follow-up
Initiate Migraine Bundle Treatment
  • Metoclopramide (IV/PO)
  • Ketorolac/Ibuprofen
  • IV fluid/ PO Hydration
  • Adjunctive Therapies
  • Reassess 45 minutes
  • Review
    • Education/home prescription regimen
      • Consider Valproic Acid tx for 2 weeks
    • Healthy habits
  • Follow up
    • Neurology
  • Review
    • Education/home prescription regimen
    • Healthy habits
  • Follow up
Reassess 45 minutes after each intervention
Assessment includes:
  • Vital signs, brief neuro exam
  • Pain scale
  • Resolution of associated symptoms
Migraine HA Medications
Medication Dose Route Max
Metoclopramide 0.2 mg/kg IV/PO 10 mg
Ketorolac* 0.5 mg/kg IV 30 mg
Ibuprofen 10 mg/kg PO 800 mg
Valproic Acid 15 mg/kg IV 1 gram
Methylprednisolone 2 mg/kg IV 200 mg
Ranitidine 1 mg/kg IV 50 mg
*Ketorolac may be given within 1 hour of last PO NSAID dose as escalation of therapy if no hx of renal insufficiency
*It can be given without HCG results unless the patient is in the 3rd trimester of pregnancy, Class D
Posted: February 2010
Revised: October 2011, April 2015, December 2015, November 2017, March 2018, August 2019
Authors: N. Hughes, MD; C. Szperka, MD; J. Lavelle, MD; C. Jacobstein, MD; D. Glatts, RN; D. Younkin, MD, N. Abend, MD; M. Chadehumbe, MD; C. Patterson Gentile MD PhD; L. Westfall CRNP; J. Zook Pharm D.