Migraine and undifferentiated headache

The ED physician frequently encounters patients with migraine headache (MH). The ergot alkaloids, available in myriad formulations, are among the oldest drugs used for MH. Clinicians noted that MH pain was often alleviated before the real analgesic was administered by prompting interest in the use of antiemetics as stand-alone therapy. Like the antiemetics, the triptans are useful in myriad benign headache syndromes. Clinical trial evidence from the ED demonstrates sumatriptan's equal efficacy in migraine, probable migraine, and tension-type headaches. Controlled trials demonstrate efficacy of multiple NSAIDs for MH pain. Among those drugs performing better than placebo are aspirin, ibuprofen, tolfenamic acid, diclofenac, and naproxen. Despite their non-specific mechanism of action, opioids are frequently used for MH. Prophylactic medications that may have ED utility in the earliest stages of migraine include the beta-blockers (e.g. metoprolol, propranolol) and the calcium channel blockers.