Key learning points

  • First or worst headache is assumed to be a subarachnoid haemorrhage, not a migraine
  • Please image all "first" migraine cases presenting to ED (particularly if an "aura" [focal neurological symptoms])


  • Migraine affects 10-20% of the US population


  • About 400,000 sufferers in Ireland
  • M:F = 1:3  (ratio reversed in children)
  • The first attack often occurs in childhood
  • Incidence increases in adolescence


  • Migraine may be related to Serotonin and Dopamine receptors in the brain
  • Triggering factors include:
    • Certain foods like chocolate, citrus fruits, cheese, Sodium Glutamate, alcohol, caffeine
    • Hormonal fluctuations, emotional stress
    • Physical Stresses - e.g. travel or change in shift work pattern
    • External stimuli

Key Clinical Features

  • Recurrent, episodic, headaches that may be unilateral or bilateral. Often throbbing
  • ± prodromal aura, with neurological symptoms (particularly visual scintillations) - in 10%
  • Attacks last hours or even days with total freedom between attacks
  • Common migraine (or migraine without aura) and classical migraine (with aura) may be accompanied by nausea (80%), vomiting, diarrhoea, photophobia or phonophobia (80%), confusion and, in rare cases, temporary paralysis and loss of speech
  • Sensitivity to light, noise and strong smells is frequently reported
  • Examination should be unremarkable
  • Beware ⇑ICP, meningism, Δ level of consciousness, localising neuro signs
  • Beware "jaw claudication" (temporal arteritis) and glaucoma (red eye, fixed pupil), particularly in the older patient


  • Investigations only to exclude other pathology if clinically suspected

Consider CT for patients with:

  • headache and an abnormal neurological exam
  • headache worsened by Valsalva manoeuvre
  • headache causing awakening from sleep
  • consider CT for new headache in older people and progressively worsening headache

Treatment and management

  • Avoid opiates
  • Metoclopramide is the drug of choice in the treatment of acute migraine in the Emergency Department Ref 1
    • (± Prochlorperazine)
  • NSAIDs ( Diclofenac 75mg PO or Indomethacin 50 mg PO or Naproxen 50mg PO)
  • Migraine specific treatments e.g. oral Sumatriptan [Cochrane], Rizatriptan [Cochrane], Eletriptan [Cochrane] or Dihydroergotamine - though these have usually already been taken prior to presentation at the Emergency Department
  • Sumatriptan is more effective than Natriptan or Rizatriptan [Bandolier]
  • Frovex 2.5 mg is also effective [Bandolier] and has a long half life (particularly suited to menstrual associated migraines)
  • Treat in a quiet dark room if possible
  • Anticonvulsants are effective in reducing the frequency of attacks but have side effects [Bandolier]
  • Propanolol has little evidence to support its use [Bandolier]
  • SSRIs are not effective at reducing attack frequency [Bandolier]
  • In patients who have received successful abortive treatment for migraine, consider a single dose of IV Dexamethasone [EMJ BestBest 2013]
  • IV MgSO4 (1-2g slow infusion) may be considered in refractory migraine

Red flags and pitfalls

  • First or worst headache is a subarachnoid haemorrhage until proven otherwise
  • A change in frequency, severity, or clinical features of the attack
  • Progressive headache that persists for days
  • Precipitation of headache with Valsalva manoeuvres (↑ ICP)
  • Age onset > 40 years, recent trauma, papilloedema
  • Repetitive / long-lasting / non-spreading aura
  • Temporal artery tenderness

Last review Dr ÍOS 15/06/21.