Updated Guidelines for Migraine Treatment in Emergency Departments Published

New clinical practice guidelines from the American Headache Society (AHS) provide updated, evidence-based recommendations for the acute treatment of migraine in adults presenting to the emergency department (ED), with a clear emphasis on parenteral therapies supported by randomized trial data. The new update to the 2016 guidelines identifies intravenous (IV) prochlorperazine and greater occipital nerve blocks (GONB) as the strongest-supported interventions that should be routinely offered to eligible patients, while discouraging the use of opioids such as hydromorphone for migraine-related pain.

The guideline was developed by a multidisciplinary working group convened by the AHS Refractory Headache Special Interest Group (SIG) and included 4 headache neurologists and 2 emergency medicine physicians. Using the same methodology as the 2016 AHS guideline, the panel conducted a systematic review of randomized controlled trials published through February 10, 2025. Searches were performed across Medline, Embase, Cochrane, clinicaltrials.gov, and the World Health Organization (WHO) International Clinical Trials Registry Platform. Evidence was graded using the American Academy of Neurology (AAN) classification system, and recommendations were assigned through the AAN guideline development process following consensus review. The update incorporated 26 randomized controlled trials evaluating 20 injectable therapies.

Key guideline recommendations include the following:

• Intravenous prochlorperazine and greater occipital nerve blocks must be offered to eligible adults with migraine requiring parenteral treatment in the ED.
• Dexketoprofen IV, ketorolac IV, metoclopramide IV, sumatriptan SC, and supraorbital nerve blocks should be offered when clinically appropriate.
• Hydromorphone IV must not be offered due to inferior efficacy and increased risk of adverse outcomes.
• Intravenous acetaminophen/paracetamol should not be offered for migraine pain relief.
• Several therapies, including ketamine, lidocaine, magnesium, and sphenopalatine ganglion blocks, received no recommendation because of insufficient ED-specific evidence.

Source: Robblee J, Minen MT, Friedman BW, Cortel-LeBlanc MA, Cortel-LeBlanc A, Orr SL. 2025 guideline update to acute treatment of migraine for adults in the emergency department: The American Headache Society evidence assessment of parenteral pharmacotherapies. Headache. Published online December 1, 2025. doi:10.1111/head.70016